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Simple Strategy for Addressing Problematic Patient Behavior
Linden Spital, NP, a psychiatric mental-health nurse practitioner, staffs the Psychiatric Consultation Liaison Service at the University of Michigan in Ann Arbor. Nearly every hospital larger than about 200 beds, she says, could benefit from a similar service, and hospitalists could play an important role in creating it.
I wrote about the idea for a generally similar service in my April 2015 column, but at the time, I didn’t know of an institution that had something like this in place.
Along with her hospitalist colleagues, Anupama (Anu) Goyal, MBChB, and Rob Chang, MD, Linden has launched a service to provide assistance to bedside caregivers dealing with very difficult patients (eg, those who are verbally or physically threatening to staff, unreasonably demanding and angry, have bizarre behavior, etc.).
Sample Cases
Two recent cases illustrate the role of the service. A female patient in her 60s had several admissions characterized by what many caregivers agreed were unreasonably precise demands regarding how her care should be delivered. She was verbally abusive of caregivers, especially those who were young or of a different race, and her family member tended to reinforce these maladaptive behaviors. Staff found it very stressful to care for her and had concerns that her care suffered as a result.
Linden served as a resource and support for staff, plus worked with providers to set limits on the patient and family behavior and to separate patient behaviors that were and weren’t modifiable. Linden’s efforts helped clarify the goals for the patient’s care and reduced staff distress. Even though the patient’s behavior didn’t change significantly, staff anecdotally reported less distress and concern that the patient’s care suffered as a result.
Another case involved a man in his 50s who had a progressive neurodegenerative disease and was admitted because of increasingly aggressive behavior in his skilled-nursing facility (SNF). Providers at the SNF attributed the poor behavior to changes in medications. His behavior was very difficult to manage, and staff asked for Linden’s help. She worked with the patient and realized much of his difficult behavior stemmed from his frustration with communicating verbally because of his neurologic disease. Rather than pursue increasing psychotropics, Linden promoted efforts to develop a system of hand signals the patient could use to communicate needs. His behavior improved, presumably by reducing his own frustration and improving his autonomy.
Atypical Consults
This psychiatric consultation liaison service has some overlap with traditional inpatient psychiatry services, but it is configured so that the caregiver is essentially embedded on the medical units of the hospital and assists in the care of patients who wouldn’t typically be appropriate for a psychiatry consult. For example, patients and/or families who act out because of anger over being on observation status are appropriate for this service but would usually not be appropriate for a psychiatry consult. The two examples above aren’t ideal cases for a standard psychiatry consult; however, the attending hospitalist needed help nonetheless.
Operational Details
The liaison service started with a successful trial on two hospital units in 2013. Linden began serving as the sole clinician on the service in January 2015. She is available during the daytime on weekdays, and any staff can request her participation in the care of a patient. Her visits are billed when appropriate, but many aren’t billed (for example, if her primary work was to conference with staff regarding management of a patient).
Consults can be requested by anyone (nurses, etc., as well as physicians, though only the latter would be billable) via an electronic health record entry that helps ensure whether the request is for this service versus the inpatient psychiatry service. The order includes a standard list of potential reasons for consult that can be selected and amplified with free text comments. She also receives verbal consult requests as she moves through the hospital.
Linden’s position is budgeted through the psychiatry department and funded by the hospital with only modest professional fee collections.
An Idea That Is Catching On?
Anu Goyal made me aware of a study from 2004 that summarized findings from experience with a similar service at Washington University in St. Louis, but the service was cancelled after a short time due to its cost.1 She also found a few studies from the 1990s and a 2001 study from Australia that report on a similar service.
But maybe the idea is catching on again, at least a little.
On April 25, The Wall Street Journal published an article titled “Hospitals Test Putting Psychiatrists on Medical Wards.”2 It described programs at Brigham and Women’s Hospital in Boston, Johns Hopkins Hospital in Baltimore, and NewYork-Presbyterian/Columbia University Medical Center in New York City. They share some similarities with the service at the University of Michigan. However, according to the article, the three big-city programs tilt more toward a traditional consultation model than what Linden does.
I think every hospital should be thinking about a service other than traditional consult psychiatry that could help with challenging patient behavior. The University of Michigan model or similar ones seem like a good place to start. TH
Reference
- Yakimo R, Kurlowicz L, Murray R. Evaluation of outcomes in psychiatric consultation-liaison nursing practice. Arch Psychiatr Nurs. 2004;18(6):215-227.
2. Ladnado L. Hospitals test putting psychiatrists on medical wards. The Wall Street Journal website. Accessed July 3, 2016.
Linden Spital, NP, a psychiatric mental-health nurse practitioner, staffs the Psychiatric Consultation Liaison Service at the University of Michigan in Ann Arbor. Nearly every hospital larger than about 200 beds, she says, could benefit from a similar service, and hospitalists could play an important role in creating it.
I wrote about the idea for a generally similar service in my April 2015 column, but at the time, I didn’t know of an institution that had something like this in place.
Along with her hospitalist colleagues, Anupama (Anu) Goyal, MBChB, and Rob Chang, MD, Linden has launched a service to provide assistance to bedside caregivers dealing with very difficult patients (eg, those who are verbally or physically threatening to staff, unreasonably demanding and angry, have bizarre behavior, etc.).
Sample Cases
Two recent cases illustrate the role of the service. A female patient in her 60s had several admissions characterized by what many caregivers agreed were unreasonably precise demands regarding how her care should be delivered. She was verbally abusive of caregivers, especially those who were young or of a different race, and her family member tended to reinforce these maladaptive behaviors. Staff found it very stressful to care for her and had concerns that her care suffered as a result.
Linden served as a resource and support for staff, plus worked with providers to set limits on the patient and family behavior and to separate patient behaviors that were and weren’t modifiable. Linden’s efforts helped clarify the goals for the patient’s care and reduced staff distress. Even though the patient’s behavior didn’t change significantly, staff anecdotally reported less distress and concern that the patient’s care suffered as a result.
Another case involved a man in his 50s who had a progressive neurodegenerative disease and was admitted because of increasingly aggressive behavior in his skilled-nursing facility (SNF). Providers at the SNF attributed the poor behavior to changes in medications. His behavior was very difficult to manage, and staff asked for Linden’s help. She worked with the patient and realized much of his difficult behavior stemmed from his frustration with communicating verbally because of his neurologic disease. Rather than pursue increasing psychotropics, Linden promoted efforts to develop a system of hand signals the patient could use to communicate needs. His behavior improved, presumably by reducing his own frustration and improving his autonomy.
Atypical Consults
This psychiatric consultation liaison service has some overlap with traditional inpatient psychiatry services, but it is configured so that the caregiver is essentially embedded on the medical units of the hospital and assists in the care of patients who wouldn’t typically be appropriate for a psychiatry consult. For example, patients and/or families who act out because of anger over being on observation status are appropriate for this service but would usually not be appropriate for a psychiatry consult. The two examples above aren’t ideal cases for a standard psychiatry consult; however, the attending hospitalist needed help nonetheless.
Operational Details
The liaison service started with a successful trial on two hospital units in 2013. Linden began serving as the sole clinician on the service in January 2015. She is available during the daytime on weekdays, and any staff can request her participation in the care of a patient. Her visits are billed when appropriate, but many aren’t billed (for example, if her primary work was to conference with staff regarding management of a patient).
Consults can be requested by anyone (nurses, etc., as well as physicians, though only the latter would be billable) via an electronic health record entry that helps ensure whether the request is for this service versus the inpatient psychiatry service. The order includes a standard list of potential reasons for consult that can be selected and amplified with free text comments. She also receives verbal consult requests as she moves through the hospital.
Linden’s position is budgeted through the psychiatry department and funded by the hospital with only modest professional fee collections.
An Idea That Is Catching On?
Anu Goyal made me aware of a study from 2004 that summarized findings from experience with a similar service at Washington University in St. Louis, but the service was cancelled after a short time due to its cost.1 She also found a few studies from the 1990s and a 2001 study from Australia that report on a similar service.
But maybe the idea is catching on again, at least a little.
On April 25, The Wall Street Journal published an article titled “Hospitals Test Putting Psychiatrists on Medical Wards.”2 It described programs at Brigham and Women’s Hospital in Boston, Johns Hopkins Hospital in Baltimore, and NewYork-Presbyterian/Columbia University Medical Center in New York City. They share some similarities with the service at the University of Michigan. However, according to the article, the three big-city programs tilt more toward a traditional consultation model than what Linden does.
I think every hospital should be thinking about a service other than traditional consult psychiatry that could help with challenging patient behavior. The University of Michigan model or similar ones seem like a good place to start. TH
Reference
- Yakimo R, Kurlowicz L, Murray R. Evaluation of outcomes in psychiatric consultation-liaison nursing practice. Arch Psychiatr Nurs. 2004;18(6):215-227.
2. Ladnado L. Hospitals test putting psychiatrists on medical wards. The Wall Street Journal website. Accessed July 3, 2016.
Linden Spital, NP, a psychiatric mental-health nurse practitioner, staffs the Psychiatric Consultation Liaison Service at the University of Michigan in Ann Arbor. Nearly every hospital larger than about 200 beds, she says, could benefit from a similar service, and hospitalists could play an important role in creating it.
I wrote about the idea for a generally similar service in my April 2015 column, but at the time, I didn’t know of an institution that had something like this in place.
Along with her hospitalist colleagues, Anupama (Anu) Goyal, MBChB, and Rob Chang, MD, Linden has launched a service to provide assistance to bedside caregivers dealing with very difficult patients (eg, those who are verbally or physically threatening to staff, unreasonably demanding and angry, have bizarre behavior, etc.).
Sample Cases
Two recent cases illustrate the role of the service. A female patient in her 60s had several admissions characterized by what many caregivers agreed were unreasonably precise demands regarding how her care should be delivered. She was verbally abusive of caregivers, especially those who were young or of a different race, and her family member tended to reinforce these maladaptive behaviors. Staff found it very stressful to care for her and had concerns that her care suffered as a result.
Linden served as a resource and support for staff, plus worked with providers to set limits on the patient and family behavior and to separate patient behaviors that were and weren’t modifiable. Linden’s efforts helped clarify the goals for the patient’s care and reduced staff distress. Even though the patient’s behavior didn’t change significantly, staff anecdotally reported less distress and concern that the patient’s care suffered as a result.
Another case involved a man in his 50s who had a progressive neurodegenerative disease and was admitted because of increasingly aggressive behavior in his skilled-nursing facility (SNF). Providers at the SNF attributed the poor behavior to changes in medications. His behavior was very difficult to manage, and staff asked for Linden’s help. She worked with the patient and realized much of his difficult behavior stemmed from his frustration with communicating verbally because of his neurologic disease. Rather than pursue increasing psychotropics, Linden promoted efforts to develop a system of hand signals the patient could use to communicate needs. His behavior improved, presumably by reducing his own frustration and improving his autonomy.
Atypical Consults
This psychiatric consultation liaison service has some overlap with traditional inpatient psychiatry services, but it is configured so that the caregiver is essentially embedded on the medical units of the hospital and assists in the care of patients who wouldn’t typically be appropriate for a psychiatry consult. For example, patients and/or families who act out because of anger over being on observation status are appropriate for this service but would usually not be appropriate for a psychiatry consult. The two examples above aren’t ideal cases for a standard psychiatry consult; however, the attending hospitalist needed help nonetheless.
Operational Details
The liaison service started with a successful trial on two hospital units in 2013. Linden began serving as the sole clinician on the service in January 2015. She is available during the daytime on weekdays, and any staff can request her participation in the care of a patient. Her visits are billed when appropriate, but many aren’t billed (for example, if her primary work was to conference with staff regarding management of a patient).
Consults can be requested by anyone (nurses, etc., as well as physicians, though only the latter would be billable) via an electronic health record entry that helps ensure whether the request is for this service versus the inpatient psychiatry service. The order includes a standard list of potential reasons for consult that can be selected and amplified with free text comments. She also receives verbal consult requests as she moves through the hospital.
Linden’s position is budgeted through the psychiatry department and funded by the hospital with only modest professional fee collections.
An Idea That Is Catching On?
Anu Goyal made me aware of a study from 2004 that summarized findings from experience with a similar service at Washington University in St. Louis, but the service was cancelled after a short time due to its cost.1 She also found a few studies from the 1990s and a 2001 study from Australia that report on a similar service.
But maybe the idea is catching on again, at least a little.
On April 25, The Wall Street Journal published an article titled “Hospitals Test Putting Psychiatrists on Medical Wards.”2 It described programs at Brigham and Women’s Hospital in Boston, Johns Hopkins Hospital in Baltimore, and NewYork-Presbyterian/Columbia University Medical Center in New York City. They share some similarities with the service at the University of Michigan. However, according to the article, the three big-city programs tilt more toward a traditional consultation model than what Linden does.
I think every hospital should be thinking about a service other than traditional consult psychiatry that could help with challenging patient behavior. The University of Michigan model or similar ones seem like a good place to start. TH
Reference
- Yakimo R, Kurlowicz L, Murray R. Evaluation of outcomes in psychiatric consultation-liaison nursing practice. Arch Psychiatr Nurs. 2004;18(6):215-227.
2. Ladnado L. Hospitals test putting psychiatrists on medical wards. The Wall Street Journal website. Accessed July 3, 2016.
PHM16: How to Design, Improve Educational Programs at Community Hospitals
Facilitators: Christopher Russo, MD, FAAP, Laura Hodo, MD, and Lauren Wilson, MD
This session discussed ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool that can be used beyond the session. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.
During the didactic session a general background of importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy”, “exposure to different career paths”, and “transfer decision-making”.
Some of the challenges discussed in regards to developing an educational structure in community settings included:
- Logistics
- Making the case for education
- Legal framework (i.e. Affiliation agreements, Liability)
- Finances (i.e. GME funding)
- Paperwork burden (ex. Licensing, Credentialing)
- Learning Environment
- Complementing clinical work with materials
- Autonomy/Supervision balancing
- Developing Clinical teachers
The didactic session also reviewed the 6 steps for curriculum development: General Needs Assessment, Targeted Needs Assessment, Goals and Objectives, Educational Strategies, Implementation, and Evaluation/Feedback. Each of these was described in further detail with relevant examples.
Groups were broken out into small groups based on four learner types: Medical Students, Family Medicine Residents, Pediatric Residents, and PHM Fellows. Within each group a “Program Development Matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.
A separate “Curriculum Development Matrix” was utilized during breakout groups that focused on curriculum development. This matrix was broken into 3 areas: Educational Strategies, Implementation, and Evaluation/Feedback. These were broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short and long term goals with action steps for both of these matrix subgroups.
Overall the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools to develop a needs assessment and planning to achieve the defined goals that can be readily used by sites who wish to develop or improve their current educational framework.
Dr. Francisco Alvarez, MD, FAAP, is a pediatric hospitalist and director of the Children's National Health System Community Hospital Services in Washington, D.C.
Facilitators: Christopher Russo, MD, FAAP, Laura Hodo, MD, and Lauren Wilson, MD
This session discussed ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool that can be used beyond the session. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.
During the didactic session a general background of importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy”, “exposure to different career paths”, and “transfer decision-making”.
Some of the challenges discussed in regards to developing an educational structure in community settings included:
- Logistics
- Making the case for education
- Legal framework (i.e. Affiliation agreements, Liability)
- Finances (i.e. GME funding)
- Paperwork burden (ex. Licensing, Credentialing)
- Learning Environment
- Complementing clinical work with materials
- Autonomy/Supervision balancing
- Developing Clinical teachers
The didactic session also reviewed the 6 steps for curriculum development: General Needs Assessment, Targeted Needs Assessment, Goals and Objectives, Educational Strategies, Implementation, and Evaluation/Feedback. Each of these was described in further detail with relevant examples.
Groups were broken out into small groups based on four learner types: Medical Students, Family Medicine Residents, Pediatric Residents, and PHM Fellows. Within each group a “Program Development Matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.
A separate “Curriculum Development Matrix” was utilized during breakout groups that focused on curriculum development. This matrix was broken into 3 areas: Educational Strategies, Implementation, and Evaluation/Feedback. These were broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short and long term goals with action steps for both of these matrix subgroups.
Overall the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools to develop a needs assessment and planning to achieve the defined goals that can be readily used by sites who wish to develop or improve their current educational framework.
Dr. Francisco Alvarez, MD, FAAP, is a pediatric hospitalist and director of the Children's National Health System Community Hospital Services in Washington, D.C.
Facilitators: Christopher Russo, MD, FAAP, Laura Hodo, MD, and Lauren Wilson, MD
This session discussed ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool that can be used beyond the session. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.
During the didactic session a general background of importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy”, “exposure to different career paths”, and “transfer decision-making”.
Some of the challenges discussed in regards to developing an educational structure in community settings included:
- Logistics
- Making the case for education
- Legal framework (i.e. Affiliation agreements, Liability)
- Finances (i.e. GME funding)
- Paperwork burden (ex. Licensing, Credentialing)
- Learning Environment
- Complementing clinical work with materials
- Autonomy/Supervision balancing
- Developing Clinical teachers
The didactic session also reviewed the 6 steps for curriculum development: General Needs Assessment, Targeted Needs Assessment, Goals and Objectives, Educational Strategies, Implementation, and Evaluation/Feedback. Each of these was described in further detail with relevant examples.
Groups were broken out into small groups based on four learner types: Medical Students, Family Medicine Residents, Pediatric Residents, and PHM Fellows. Within each group a “Program Development Matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.
A separate “Curriculum Development Matrix” was utilized during breakout groups that focused on curriculum development. This matrix was broken into 3 areas: Educational Strategies, Implementation, and Evaluation/Feedback. These were broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short and long term goals with action steps for both of these matrix subgroups.
Overall the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools to develop a needs assessment and planning to achieve the defined goals that can be readily used by sites who wish to develop or improve their current educational framework.
Dr. Francisco Alvarez, MD, FAAP, is a pediatric hospitalist and director of the Children's National Health System Community Hospital Services in Washington, D.C.
Should Physicians Care about Costs?
The healthcare industry is under major stress from steady declines in all sources of revenue. The drivers are multifactorial but include declining reimbursement from payors, a shift from fee-for-service to pay-for-performance, and state-by-state variability in patients covered by Medicaid, by high-deductible plans, or by being uninsured. In academic medical centers, rising overhead costs coupled with a reticence to raise student tuition and declining research funding streams have further compounded the situation.
Regardless of the actual numbers, all healthcare institutions are feeling the financial pinch. Most are intensely focused on cost-reduction efforts. The question is, what do physicians think about their role in these efforts, and what efforts will be most effective?
A recent survey of a large physician group practice found that many physicians do not know what their cost drivers are or do not think it is their role to participate in cost-reduction efforts.1 Of note, the group practice in the survey is a Pioneer Medicare accountable care organization (ACO) and participates in a combination of fee-for-service and capitated contracts.
Within the survey, the researchers embedded a cost-consciousness scale, which is a validated survey tool designed to assess daily cost consciousness. They also embedded other survey items to determine the physicians’ concerns for malpractice, comfort with diagnostic uncertainty, and perception of patient-family pressure for utilization of services. The average overall cost-consciousness score was 29 out of 44, with higher scores indicating more cost consciousness.
Almost all physicians agreed that they need to reduce unnecessary testing (97%), need to adhere to guidelines (98%), and have a responsibility to control costs (92%). However, 33% felt it was unfair for them to have to be both cost-conscious and concerned with the welfare of their patients.
Approximately a third of respondents also felt that there was too much emphasis on cost and that physicians are too busy to worry about costs.
More than a third (37%) said they did not have good knowledge about test-procedure cost within their system.
More than half of physicians felt pressure from patients to perform tests and procedures (from 68% of primary-care physicians, 58% of medical specialists, and 56% of surgical specialists) and felt pressure to refer to consultants (from 65% of primary-care physicians, 35% of medical specialists, and 34% of surgical specialists).
Based on this survey and other literature about physicians’ perceptions of their role and their ability to control costs, it is clear that the first step in understanding how to engage physicians in cost-reducing efforts is to understand what the drivers are for utilization and what the concerns are for reducing cost. Many hypothesize that the drivers to support the status quo include a fear of litigation, fear of missing a diagnosis, and patient demands for services. Another major driver of current utilization is that there is ongoing support for the status quo, as the majority of reimbursement for providers is still based on fee-for-service.
Change Efforts
One cost-reducing effort that has gained widespread enthusiasm from medical societies is the Choosing Wisely campaign. This campaign is an effort originally driven by the American Board of Internal Medicine (ABIM) Foundation to help physicians become aware of and reduce unnecessary utilization of resources. Each Choosing Wisely list is generated and endorsed by the relevant medical society and widely advertised to physicians via a variety of mechanisms. More than 70 medical societies have participated in the effort to date.
The recommendations are often widely accepted by those in the specialty since they are evidence-based and derived and advertised by their own specialty societies. In the survey mentioned above, almost all physicians agreed that their Choosing Wisely was a good source of guidance (ranging from 92% of surgical specialties to 97% of primary-care physicians). In order to drive the movement from the patient perspective, Consumer Reports has developed educational materials aimed at the consumer side of healthcare (ie, patients and families).
As Consumer Reports suggests, the first step to implementing cost-conscious care is to measure awareness of cost and causes of overutilization. By first understanding behaviors, a group can then work to impact such behaviors. It is highly likely that the drivers are different based on the specialty of the physician, the patient population being served, and the local healthcare market drivers. As such, there will not be a single, across-the-board solution to reducing unnecessary utilization of services (and therefore cost), but interventions will need to be tailored to different groups depending on the drivers of cost locally.
Depending on the issues within a group, successful interventions could include:
- Decision support tools (for appropriate use of consultants and diagnostic tests)
- Display of testing costs (not just at the time of ordering)
- Efforts aimed at patient education (both as general consumers as well as at the point of care)
- Malpractice reform to support physicians trying to balance cost consciousness with patient welfare
In Sum
We have a long way to go in engaging physicians in efforts to reduce unnecessary utilization and cost. I recommend that hospitalist practices utilize the survey tool used in this study to understand the perceived barriers and drivers of cost within their practice and work with their local administrative teams to better understand patterns of overutilization among their group. Then interventions can be designed to be evidence-based, tailored to local workflow, and both reliable and sustainable.
If done well, hospitalists can have a huge impact on utilization and cost and position their groups and their hospitals well to succeed in this cost-constrained era of healthcare. TH
References
- Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perception of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016;22(5):337-343.
The healthcare industry is under major stress from steady declines in all sources of revenue. The drivers are multifactorial but include declining reimbursement from payors, a shift from fee-for-service to pay-for-performance, and state-by-state variability in patients covered by Medicaid, by high-deductible plans, or by being uninsured. In academic medical centers, rising overhead costs coupled with a reticence to raise student tuition and declining research funding streams have further compounded the situation.
Regardless of the actual numbers, all healthcare institutions are feeling the financial pinch. Most are intensely focused on cost-reduction efforts. The question is, what do physicians think about their role in these efforts, and what efforts will be most effective?
A recent survey of a large physician group practice found that many physicians do not know what their cost drivers are or do not think it is their role to participate in cost-reduction efforts.1 Of note, the group practice in the survey is a Pioneer Medicare accountable care organization (ACO) and participates in a combination of fee-for-service and capitated contracts.
Within the survey, the researchers embedded a cost-consciousness scale, which is a validated survey tool designed to assess daily cost consciousness. They also embedded other survey items to determine the physicians’ concerns for malpractice, comfort with diagnostic uncertainty, and perception of patient-family pressure for utilization of services. The average overall cost-consciousness score was 29 out of 44, with higher scores indicating more cost consciousness.
Almost all physicians agreed that they need to reduce unnecessary testing (97%), need to adhere to guidelines (98%), and have a responsibility to control costs (92%). However, 33% felt it was unfair for them to have to be both cost-conscious and concerned with the welfare of their patients.
Approximately a third of respondents also felt that there was too much emphasis on cost and that physicians are too busy to worry about costs.
More than a third (37%) said they did not have good knowledge about test-procedure cost within their system.
More than half of physicians felt pressure from patients to perform tests and procedures (from 68% of primary-care physicians, 58% of medical specialists, and 56% of surgical specialists) and felt pressure to refer to consultants (from 65% of primary-care physicians, 35% of medical specialists, and 34% of surgical specialists).
Based on this survey and other literature about physicians’ perceptions of their role and their ability to control costs, it is clear that the first step in understanding how to engage physicians in cost-reducing efforts is to understand what the drivers are for utilization and what the concerns are for reducing cost. Many hypothesize that the drivers to support the status quo include a fear of litigation, fear of missing a diagnosis, and patient demands for services. Another major driver of current utilization is that there is ongoing support for the status quo, as the majority of reimbursement for providers is still based on fee-for-service.
Change Efforts
One cost-reducing effort that has gained widespread enthusiasm from medical societies is the Choosing Wisely campaign. This campaign is an effort originally driven by the American Board of Internal Medicine (ABIM) Foundation to help physicians become aware of and reduce unnecessary utilization of resources. Each Choosing Wisely list is generated and endorsed by the relevant medical society and widely advertised to physicians via a variety of mechanisms. More than 70 medical societies have participated in the effort to date.
The recommendations are often widely accepted by those in the specialty since they are evidence-based and derived and advertised by their own specialty societies. In the survey mentioned above, almost all physicians agreed that their Choosing Wisely was a good source of guidance (ranging from 92% of surgical specialties to 97% of primary-care physicians). In order to drive the movement from the patient perspective, Consumer Reports has developed educational materials aimed at the consumer side of healthcare (ie, patients and families).
As Consumer Reports suggests, the first step to implementing cost-conscious care is to measure awareness of cost and causes of overutilization. By first understanding behaviors, a group can then work to impact such behaviors. It is highly likely that the drivers are different based on the specialty of the physician, the patient population being served, and the local healthcare market drivers. As such, there will not be a single, across-the-board solution to reducing unnecessary utilization of services (and therefore cost), but interventions will need to be tailored to different groups depending on the drivers of cost locally.
Depending on the issues within a group, successful interventions could include:
- Decision support tools (for appropriate use of consultants and diagnostic tests)
- Display of testing costs (not just at the time of ordering)
- Efforts aimed at patient education (both as general consumers as well as at the point of care)
- Malpractice reform to support physicians trying to balance cost consciousness with patient welfare
In Sum
We have a long way to go in engaging physicians in efforts to reduce unnecessary utilization and cost. I recommend that hospitalist practices utilize the survey tool used in this study to understand the perceived barriers and drivers of cost within their practice and work with their local administrative teams to better understand patterns of overutilization among their group. Then interventions can be designed to be evidence-based, tailored to local workflow, and both reliable and sustainable.
If done well, hospitalists can have a huge impact on utilization and cost and position their groups and their hospitals well to succeed in this cost-constrained era of healthcare. TH
References
- Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perception of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016;22(5):337-343.
The healthcare industry is under major stress from steady declines in all sources of revenue. The drivers are multifactorial but include declining reimbursement from payors, a shift from fee-for-service to pay-for-performance, and state-by-state variability in patients covered by Medicaid, by high-deductible plans, or by being uninsured. In academic medical centers, rising overhead costs coupled with a reticence to raise student tuition and declining research funding streams have further compounded the situation.
Regardless of the actual numbers, all healthcare institutions are feeling the financial pinch. Most are intensely focused on cost-reduction efforts. The question is, what do physicians think about their role in these efforts, and what efforts will be most effective?
A recent survey of a large physician group practice found that many physicians do not know what their cost drivers are or do not think it is their role to participate in cost-reduction efforts.1 Of note, the group practice in the survey is a Pioneer Medicare accountable care organization (ACO) and participates in a combination of fee-for-service and capitated contracts.
Within the survey, the researchers embedded a cost-consciousness scale, which is a validated survey tool designed to assess daily cost consciousness. They also embedded other survey items to determine the physicians’ concerns for malpractice, comfort with diagnostic uncertainty, and perception of patient-family pressure for utilization of services. The average overall cost-consciousness score was 29 out of 44, with higher scores indicating more cost consciousness.
Almost all physicians agreed that they need to reduce unnecessary testing (97%), need to adhere to guidelines (98%), and have a responsibility to control costs (92%). However, 33% felt it was unfair for them to have to be both cost-conscious and concerned with the welfare of their patients.
Approximately a third of respondents also felt that there was too much emphasis on cost and that physicians are too busy to worry about costs.
More than a third (37%) said they did not have good knowledge about test-procedure cost within their system.
More than half of physicians felt pressure from patients to perform tests and procedures (from 68% of primary-care physicians, 58% of medical specialists, and 56% of surgical specialists) and felt pressure to refer to consultants (from 65% of primary-care physicians, 35% of medical specialists, and 34% of surgical specialists).
Based on this survey and other literature about physicians’ perceptions of their role and their ability to control costs, it is clear that the first step in understanding how to engage physicians in cost-reducing efforts is to understand what the drivers are for utilization and what the concerns are for reducing cost. Many hypothesize that the drivers to support the status quo include a fear of litigation, fear of missing a diagnosis, and patient demands for services. Another major driver of current utilization is that there is ongoing support for the status quo, as the majority of reimbursement for providers is still based on fee-for-service.
Change Efforts
One cost-reducing effort that has gained widespread enthusiasm from medical societies is the Choosing Wisely campaign. This campaign is an effort originally driven by the American Board of Internal Medicine (ABIM) Foundation to help physicians become aware of and reduce unnecessary utilization of resources. Each Choosing Wisely list is generated and endorsed by the relevant medical society and widely advertised to physicians via a variety of mechanisms. More than 70 medical societies have participated in the effort to date.
The recommendations are often widely accepted by those in the specialty since they are evidence-based and derived and advertised by their own specialty societies. In the survey mentioned above, almost all physicians agreed that their Choosing Wisely was a good source of guidance (ranging from 92% of surgical specialties to 97% of primary-care physicians). In order to drive the movement from the patient perspective, Consumer Reports has developed educational materials aimed at the consumer side of healthcare (ie, patients and families).
As Consumer Reports suggests, the first step to implementing cost-conscious care is to measure awareness of cost and causes of overutilization. By first understanding behaviors, a group can then work to impact such behaviors. It is highly likely that the drivers are different based on the specialty of the physician, the patient population being served, and the local healthcare market drivers. As such, there will not be a single, across-the-board solution to reducing unnecessary utilization of services (and therefore cost), but interventions will need to be tailored to different groups depending on the drivers of cost locally.
Depending on the issues within a group, successful interventions could include:
- Decision support tools (for appropriate use of consultants and diagnostic tests)
- Display of testing costs (not just at the time of ordering)
- Efforts aimed at patient education (both as general consumers as well as at the point of care)
- Malpractice reform to support physicians trying to balance cost consciousness with patient welfare
In Sum
We have a long way to go in engaging physicians in efforts to reduce unnecessary utilization and cost. I recommend that hospitalist practices utilize the survey tool used in this study to understand the perceived barriers and drivers of cost within their practice and work with their local administrative teams to better understand patterns of overutilization among their group. Then interventions can be designed to be evidence-based, tailored to local workflow, and both reliable and sustainable.
If done well, hospitalists can have a huge impact on utilization and cost and position their groups and their hospitals well to succeed in this cost-constrained era of healthcare. TH
References
- Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perception of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016;22(5):337-343.
Reducing Drug Expenditure with Computerized Alerts
Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.
“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”
“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”
The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.
“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P
Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”
Reference
- Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.
Quick Byte
Telehealth Expansion
In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.
Reference
1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.
Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.
“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”
“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”
The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.
“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P
Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”
Reference
- Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.
Quick Byte
Telehealth Expansion
In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.
Reference
1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.
Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.
“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”
“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”
The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.
“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P
Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”
Reference
- Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.
Quick Byte
Telehealth Expansion
In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.
Reference
1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.
As Summer—and Interns—Roll In, Try a Little Empathy on Your Patients, Colleagues
It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.
When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.
I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.
Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.
Most important, he listened and didn’t judge.
Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.
As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.
But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.
We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.
So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.
As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.
Happy July, everyone! TH
It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.
When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.
I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.
Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.
Most important, he listened and didn’t judge.
Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.
As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.
But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.
We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.
So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.
As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.
Happy July, everyone! TH
It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.
When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.
I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.
Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.
Most important, he listened and didn’t judge.
Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.
As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.
But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.
We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.
So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.
As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.
Happy July, everyone! TH
Who to Blame for Surgical Readmissions?
When too many surgery patients are readmitted, the hospital can be fined by the federal government - but a new study suggests many of those readmissions are not the hospital's fault.
Many readmissions were due to issues like drug abuse or homelessness, the researchers found. Less than one in five patients returned to the hospital due to something doctors could have managed better.
"Very few were due to reasons we could control with better medical care at the index admission," said lead author Dr. Lisa McIntyre, of Harbourview Medical Center in Seattle.
McIntyre and her colleagues noted June 15 in JAMA Surgery that the U.S. government began fining hospitals in 2015 for surgery readmission rates that are higher than expected. Fines were already being imposed since 2012 for readmissions following treatments for various medical conditions.
The researchers studied the medical records of patients who were discharged from their hospital's general surgery department in 2014 or 2015 and readmitted within 30 days.
Out of the 2,100 discharges during that time, there were 173 unplanned readmissions. About 17% of those readmissions were due to injection drug use and about 15% were due to issues like homelessness or difficulty getting to follow-up appointments.
Only about 18% of readmissions - about 2% of all discharges - were due to potentially avoidable problems following surgery.
While the results are only from a single hospital, that hospital is also a safety-net facility for the local area - and McIntyre pointed out that all hospitals have some amount of disadvantaged patients.
"To be able to affect this rate, there are going to need to be new interventions that require money and a more global care package of each individual patient that doesn't stop at discharge," said McIntyre, who is also affiliated with the University of Washington.
Being female, having diabetes, having sepsis upon admission, being in the ICU and being discharged to respite care were all tied to an increased risk of readmission, the researchers found.
The results raise the question of whether readmission rates are valuable measures of surgical quality, write Drs. Alexander Schwed and Christian de Virgilio of the University of California, Los Angeles in an editorial.
Some would argue that readmitting patients is a sound medical decision that is tied to lower risks of death, they write.
"Should such an inexact marker of quality be used to financially penalize hospitals?" they ask. "Health services researchers (need to find) a better marker for surgical quality that is reliably calculable and clinically useful."
SOURCE: http://bit.ly/28Km3aH and http://bit.ly/28Km3Ye JAMA Surgery 2016.
When too many surgery patients are readmitted, the hospital can be fined by the federal government - but a new study suggests many of those readmissions are not the hospital's fault.
Many readmissions were due to issues like drug abuse or homelessness, the researchers found. Less than one in five patients returned to the hospital due to something doctors could have managed better.
"Very few were due to reasons we could control with better medical care at the index admission," said lead author Dr. Lisa McIntyre, of Harbourview Medical Center in Seattle.
McIntyre and her colleagues noted June 15 in JAMA Surgery that the U.S. government began fining hospitals in 2015 for surgery readmission rates that are higher than expected. Fines were already being imposed since 2012 for readmissions following treatments for various medical conditions.
The researchers studied the medical records of patients who were discharged from their hospital's general surgery department in 2014 or 2015 and readmitted within 30 days.
Out of the 2,100 discharges during that time, there were 173 unplanned readmissions. About 17% of those readmissions were due to injection drug use and about 15% were due to issues like homelessness or difficulty getting to follow-up appointments.
Only about 18% of readmissions - about 2% of all discharges - were due to potentially avoidable problems following surgery.
While the results are only from a single hospital, that hospital is also a safety-net facility for the local area - and McIntyre pointed out that all hospitals have some amount of disadvantaged patients.
"To be able to affect this rate, there are going to need to be new interventions that require money and a more global care package of each individual patient that doesn't stop at discharge," said McIntyre, who is also affiliated with the University of Washington.
Being female, having diabetes, having sepsis upon admission, being in the ICU and being discharged to respite care were all tied to an increased risk of readmission, the researchers found.
The results raise the question of whether readmission rates are valuable measures of surgical quality, write Drs. Alexander Schwed and Christian de Virgilio of the University of California, Los Angeles in an editorial.
Some would argue that readmitting patients is a sound medical decision that is tied to lower risks of death, they write.
"Should such an inexact marker of quality be used to financially penalize hospitals?" they ask. "Health services researchers (need to find) a better marker for surgical quality that is reliably calculable and clinically useful."
SOURCE: http://bit.ly/28Km3aH and http://bit.ly/28Km3Ye JAMA Surgery 2016.
When too many surgery patients are readmitted, the hospital can be fined by the federal government - but a new study suggests many of those readmissions are not the hospital's fault.
Many readmissions were due to issues like drug abuse or homelessness, the researchers found. Less than one in five patients returned to the hospital due to something doctors could have managed better.
"Very few were due to reasons we could control with better medical care at the index admission," said lead author Dr. Lisa McIntyre, of Harbourview Medical Center in Seattle.
McIntyre and her colleagues noted June 15 in JAMA Surgery that the U.S. government began fining hospitals in 2015 for surgery readmission rates that are higher than expected. Fines were already being imposed since 2012 for readmissions following treatments for various medical conditions.
The researchers studied the medical records of patients who were discharged from their hospital's general surgery department in 2014 or 2015 and readmitted within 30 days.
Out of the 2,100 discharges during that time, there were 173 unplanned readmissions. About 17% of those readmissions were due to injection drug use and about 15% were due to issues like homelessness or difficulty getting to follow-up appointments.
Only about 18% of readmissions - about 2% of all discharges - were due to potentially avoidable problems following surgery.
While the results are only from a single hospital, that hospital is also a safety-net facility for the local area - and McIntyre pointed out that all hospitals have some amount of disadvantaged patients.
"To be able to affect this rate, there are going to need to be new interventions that require money and a more global care package of each individual patient that doesn't stop at discharge," said McIntyre, who is also affiliated with the University of Washington.
Being female, having diabetes, having sepsis upon admission, being in the ICU and being discharged to respite care were all tied to an increased risk of readmission, the researchers found.
The results raise the question of whether readmission rates are valuable measures of surgical quality, write Drs. Alexander Schwed and Christian de Virgilio of the University of California, Los Angeles in an editorial.
Some would argue that readmitting patients is a sound medical decision that is tied to lower risks of death, they write.
"Should such an inexact marker of quality be used to financially penalize hospitals?" they ask. "Health services researchers (need to find) a better marker for surgical quality that is reliably calculable and clinically useful."
SOURCE: http://bit.ly/28Km3aH and http://bit.ly/28Km3Ye JAMA Surgery 2016.
Lesson in Improper Allocations, Unaccounted for NP/PA Contributions
I visited during a hot Florida summer in the mid 1990s and could readily see that the practice was great in most respects. The large multispecialty group had recruited talented hospitalists and had put in place effective operational practices. All seemed to be going well, but inappropriate overhead allocation was undermining the success of their efforts.
The multispecialty group employing the hospitalists used the same formula to allocate overhead to the hospitalists that was in place for other specialties. And compensation was essentially each doctor’s collections minus overhead, leaving the hospitalists with annual compensation much lower than they could reasonably expect. With the group deducting from hospitalist collections the same overhead expenses charged to other specialties, including a share of outpatient buildings, staff, and supplies, the hospitalists were paying a lot for services they weren’t using. This group corrected the errors but not until some talented doctors had resigned because of the compensation formula.
This was a common mistake made by multispecialty groups that employed hospitalists years ago. Today, nearly all such groups assess an appropriately smaller portion of overhead to hospitalists than office-based doctors.
Typical Hospitalist Overhead
It is still tricky to correctly assess and allocate hospitalist overhead. This meaningfully influences the apparent total cost of the program and hence the amount of support paid by the hospital or other entity. (This support is often referred to as a “subsidy,” though I don’t care for that term because of its negative connotation.)
For example, costs for billing and collections services, malpractice insurance, temporary staffing (locums), and an overhead allocation that pays for things like the salaries of medical group administrators and clerical staff may or may not be attributed to the hospitalist budget or “cost center.” This is one of several factors that make it awfully tricky to compare the total costs and/or hospital financial support between different hospitalist groups.
SHM’s State of Hospital Medicine report includes detailed instructions regarding which expenses the survey respondents should include as overhead costs, but I think it’s safe to assume that not all responses are fully compliant. I’m confident there is a meaningful amount of “noise” in these figures. Numbers like the median financial support per FTE hospitalist per year ($156,063 in the 2014 report) should only be used as a guideline and not a precise number that might apply in your setting. My reasoning is that the collections rate and compensation amount can vary tremendously from one practice to another and will typically have a far larger influence on the amount of financial support provided by the hospital than which expenses are or aren’t included as overhead. But I am confining this discussion to the latter.
APC Costs: One Factor Driving Increased Support
SHM has been surveying the financial support per physician FTE for about 15 years, and it has shown a steady increase. It was about $60,000 per FTE annually when first surveyed in the late 1990s; it has gone up every survey since. The best explanation for this seems to an increase in hospitalist compensation while production and revenue have remained relatively flat.
There likely are many other factors in play. One important one is physician assistant and nurse practitioner costs. The survey divides the total annual support provided to the whole hospitalist practice by the total number of physician FTEs. NPs and PAs are becoming more common in hospitalist groups; 65% of groups included them in 2014, up from 54% in 2012. Yet the cost of employing them, primarily salary and benefits, appears in the numerator but not the denominator of the support per physician FTE figure.
This means a group that adds NP/PA staffing, which typically requires an accompanying increase in hospital financial support, while maintaining the same number of physician FTEs will show an increase in hospital support per physician FTE. But this fails to capture that the practice’s work product (i.e., patients seen) has increased as a result of increasing its clinical staff.
This is a tricky issue to fix. SHM’s Practice Analysis Committee, which manages the survey, is aware of the issue and may make future adjustments to account for it. The best method might be to convert total staffing by physicians and NP/PAs into physician-equivalent FTEs (I described one method for doing this in my August 2009 column titled “Volume Variables”) or some other method that clearly accounts for both physician and NP/PA staffing levels. Other alternatives would be to divide the annual support by the number of billed encounters or some other measure of “work output” or to report percent of the total practice revenue that comes from hospital support versus professional fee collections and other sources.
Why Allocation of NP/PA Costs and FTEs Matter
Another way to think of this issue is that including NP/PA costs but not their work (FTEs) in the financial support per FTE figure overlooks the important work they can do for a hospitalist practice. And it can lead one to conclude hospitals’ costs per clinician FTE are rising faster than is actually the case.
This is only one of the tricky issues in accurately understanding hospitalist overhead and costs to the hospital they serve. TH
I visited during a hot Florida summer in the mid 1990s and could readily see that the practice was great in most respects. The large multispecialty group had recruited talented hospitalists and had put in place effective operational practices. All seemed to be going well, but inappropriate overhead allocation was undermining the success of their efforts.
The multispecialty group employing the hospitalists used the same formula to allocate overhead to the hospitalists that was in place for other specialties. And compensation was essentially each doctor’s collections minus overhead, leaving the hospitalists with annual compensation much lower than they could reasonably expect. With the group deducting from hospitalist collections the same overhead expenses charged to other specialties, including a share of outpatient buildings, staff, and supplies, the hospitalists were paying a lot for services they weren’t using. This group corrected the errors but not until some talented doctors had resigned because of the compensation formula.
This was a common mistake made by multispecialty groups that employed hospitalists years ago. Today, nearly all such groups assess an appropriately smaller portion of overhead to hospitalists than office-based doctors.
Typical Hospitalist Overhead
It is still tricky to correctly assess and allocate hospitalist overhead. This meaningfully influences the apparent total cost of the program and hence the amount of support paid by the hospital or other entity. (This support is often referred to as a “subsidy,” though I don’t care for that term because of its negative connotation.)
For example, costs for billing and collections services, malpractice insurance, temporary staffing (locums), and an overhead allocation that pays for things like the salaries of medical group administrators and clerical staff may or may not be attributed to the hospitalist budget or “cost center.” This is one of several factors that make it awfully tricky to compare the total costs and/or hospital financial support between different hospitalist groups.
SHM’s State of Hospital Medicine report includes detailed instructions regarding which expenses the survey respondents should include as overhead costs, but I think it’s safe to assume that not all responses are fully compliant. I’m confident there is a meaningful amount of “noise” in these figures. Numbers like the median financial support per FTE hospitalist per year ($156,063 in the 2014 report) should only be used as a guideline and not a precise number that might apply in your setting. My reasoning is that the collections rate and compensation amount can vary tremendously from one practice to another and will typically have a far larger influence on the amount of financial support provided by the hospital than which expenses are or aren’t included as overhead. But I am confining this discussion to the latter.
APC Costs: One Factor Driving Increased Support
SHM has been surveying the financial support per physician FTE for about 15 years, and it has shown a steady increase. It was about $60,000 per FTE annually when first surveyed in the late 1990s; it has gone up every survey since. The best explanation for this seems to an increase in hospitalist compensation while production and revenue have remained relatively flat.
There likely are many other factors in play. One important one is physician assistant and nurse practitioner costs. The survey divides the total annual support provided to the whole hospitalist practice by the total number of physician FTEs. NPs and PAs are becoming more common in hospitalist groups; 65% of groups included them in 2014, up from 54% in 2012. Yet the cost of employing them, primarily salary and benefits, appears in the numerator but not the denominator of the support per physician FTE figure.
This means a group that adds NP/PA staffing, which typically requires an accompanying increase in hospital financial support, while maintaining the same number of physician FTEs will show an increase in hospital support per physician FTE. But this fails to capture that the practice’s work product (i.e., patients seen) has increased as a result of increasing its clinical staff.
This is a tricky issue to fix. SHM’s Practice Analysis Committee, which manages the survey, is aware of the issue and may make future adjustments to account for it. The best method might be to convert total staffing by physicians and NP/PAs into physician-equivalent FTEs (I described one method for doing this in my August 2009 column titled “Volume Variables”) or some other method that clearly accounts for both physician and NP/PA staffing levels. Other alternatives would be to divide the annual support by the number of billed encounters or some other measure of “work output” or to report percent of the total practice revenue that comes from hospital support versus professional fee collections and other sources.
Why Allocation of NP/PA Costs and FTEs Matter
Another way to think of this issue is that including NP/PA costs but not their work (FTEs) in the financial support per FTE figure overlooks the important work they can do for a hospitalist practice. And it can lead one to conclude hospitals’ costs per clinician FTE are rising faster than is actually the case.
This is only one of the tricky issues in accurately understanding hospitalist overhead and costs to the hospital they serve. TH
I visited during a hot Florida summer in the mid 1990s and could readily see that the practice was great in most respects. The large multispecialty group had recruited talented hospitalists and had put in place effective operational practices. All seemed to be going well, but inappropriate overhead allocation was undermining the success of their efforts.
The multispecialty group employing the hospitalists used the same formula to allocate overhead to the hospitalists that was in place for other specialties. And compensation was essentially each doctor’s collections minus overhead, leaving the hospitalists with annual compensation much lower than they could reasonably expect. With the group deducting from hospitalist collections the same overhead expenses charged to other specialties, including a share of outpatient buildings, staff, and supplies, the hospitalists were paying a lot for services they weren’t using. This group corrected the errors but not until some talented doctors had resigned because of the compensation formula.
This was a common mistake made by multispecialty groups that employed hospitalists years ago. Today, nearly all such groups assess an appropriately smaller portion of overhead to hospitalists than office-based doctors.
Typical Hospitalist Overhead
It is still tricky to correctly assess and allocate hospitalist overhead. This meaningfully influences the apparent total cost of the program and hence the amount of support paid by the hospital or other entity. (This support is often referred to as a “subsidy,” though I don’t care for that term because of its negative connotation.)
For example, costs for billing and collections services, malpractice insurance, temporary staffing (locums), and an overhead allocation that pays for things like the salaries of medical group administrators and clerical staff may or may not be attributed to the hospitalist budget or “cost center.” This is one of several factors that make it awfully tricky to compare the total costs and/or hospital financial support between different hospitalist groups.
SHM’s State of Hospital Medicine report includes detailed instructions regarding which expenses the survey respondents should include as overhead costs, but I think it’s safe to assume that not all responses are fully compliant. I’m confident there is a meaningful amount of “noise” in these figures. Numbers like the median financial support per FTE hospitalist per year ($156,063 in the 2014 report) should only be used as a guideline and not a precise number that might apply in your setting. My reasoning is that the collections rate and compensation amount can vary tremendously from one practice to another and will typically have a far larger influence on the amount of financial support provided by the hospital than which expenses are or aren’t included as overhead. But I am confining this discussion to the latter.
APC Costs: One Factor Driving Increased Support
SHM has been surveying the financial support per physician FTE for about 15 years, and it has shown a steady increase. It was about $60,000 per FTE annually when first surveyed in the late 1990s; it has gone up every survey since. The best explanation for this seems to an increase in hospitalist compensation while production and revenue have remained relatively flat.
There likely are many other factors in play. One important one is physician assistant and nurse practitioner costs. The survey divides the total annual support provided to the whole hospitalist practice by the total number of physician FTEs. NPs and PAs are becoming more common in hospitalist groups; 65% of groups included them in 2014, up from 54% in 2012. Yet the cost of employing them, primarily salary and benefits, appears in the numerator but not the denominator of the support per physician FTE figure.
This means a group that adds NP/PA staffing, which typically requires an accompanying increase in hospital financial support, while maintaining the same number of physician FTEs will show an increase in hospital support per physician FTE. But this fails to capture that the practice’s work product (i.e., patients seen) has increased as a result of increasing its clinical staff.
This is a tricky issue to fix. SHM’s Practice Analysis Committee, which manages the survey, is aware of the issue and may make future adjustments to account for it. The best method might be to convert total staffing by physicians and NP/PAs into physician-equivalent FTEs (I described one method for doing this in my August 2009 column titled “Volume Variables”) or some other method that clearly accounts for both physician and NP/PA staffing levels. Other alternatives would be to divide the annual support by the number of billed encounters or some other measure of “work output” or to report percent of the total practice revenue that comes from hospital support versus professional fee collections and other sources.
Why Allocation of NP/PA Costs and FTEs Matter
Another way to think of this issue is that including NP/PA costs but not their work (FTEs) in the financial support per FTE figure overlooks the important work they can do for a hospitalist practice. And it can lead one to conclude hospitals’ costs per clinician FTE are rising faster than is actually the case.
This is only one of the tricky issues in accurately understanding hospitalist overhead and costs to the hospital they serve. TH
Applying Military Principles to HM Leadership
Hospitalists are more than doctors—they are also leaders in their organizations, which is why a new book by retired Army Lieutenant General Mark Hertling is relevant to what they do every day. Hertling, whose numerous military awards include the Legion of Merit, the Bronze Star, and the Purple Heart, is the author of Growing Physician Leaders: Empowering Doctors to Improve Our Healthcare, which applies his four decades of military leadership to the world of healthcare.
He wrote the book not long after designing the first physician leader course at Florida Hospital in Orlando.
“Many of the administrators and other doctors saw the changes in the doctors, nurses, and administrators who graduated from the course, and they asked me to write down what we had done,” he says. “The book is partially a description of the course, but it’s also a primer on the basics of leadership.”
The book tells readers how to understand what kind of leader they can be as well as how to better understand the motivations of others; it also outlines a variety of influence techniques they can employ to get things done.
“One of the things we drive home is that all physicians are leaders, whether they are in a leadership role or not,” Hertling says.
One of the concepts he outlines is “leading up”—how to influence your bosses to do the things you want them to do. “What we do during this lesson is show readers how they are other people’s bosses, too,” he says, “and that they need to listen to their own people, too, and allow their folks to contribute to the organizational goals.”
Hospitalists are more than doctors—they are also leaders in their organizations, which is why a new book by retired Army Lieutenant General Mark Hertling is relevant to what they do every day. Hertling, whose numerous military awards include the Legion of Merit, the Bronze Star, and the Purple Heart, is the author of Growing Physician Leaders: Empowering Doctors to Improve Our Healthcare, which applies his four decades of military leadership to the world of healthcare.
He wrote the book not long after designing the first physician leader course at Florida Hospital in Orlando.
“Many of the administrators and other doctors saw the changes in the doctors, nurses, and administrators who graduated from the course, and they asked me to write down what we had done,” he says. “The book is partially a description of the course, but it’s also a primer on the basics of leadership.”
The book tells readers how to understand what kind of leader they can be as well as how to better understand the motivations of others; it also outlines a variety of influence techniques they can employ to get things done.
“One of the things we drive home is that all physicians are leaders, whether they are in a leadership role or not,” Hertling says.
One of the concepts he outlines is “leading up”—how to influence your bosses to do the things you want them to do. “What we do during this lesson is show readers how they are other people’s bosses, too,” he says, “and that they need to listen to their own people, too, and allow their folks to contribute to the organizational goals.”
Hospitalists are more than doctors—they are also leaders in their organizations, which is why a new book by retired Army Lieutenant General Mark Hertling is relevant to what they do every day. Hertling, whose numerous military awards include the Legion of Merit, the Bronze Star, and the Purple Heart, is the author of Growing Physician Leaders: Empowering Doctors to Improve Our Healthcare, which applies his four decades of military leadership to the world of healthcare.
He wrote the book not long after designing the first physician leader course at Florida Hospital in Orlando.
“Many of the administrators and other doctors saw the changes in the doctors, nurses, and administrators who graduated from the course, and they asked me to write down what we had done,” he says. “The book is partially a description of the course, but it’s also a primer on the basics of leadership.”
The book tells readers how to understand what kind of leader they can be as well as how to better understand the motivations of others; it also outlines a variety of influence techniques they can employ to get things done.
“One of the things we drive home is that all physicians are leaders, whether they are in a leadership role or not,” Hertling says.
One of the concepts he outlines is “leading up”—how to influence your bosses to do the things you want them to do. “What we do during this lesson is show readers how they are other people’s bosses, too,” he says, “and that they need to listen to their own people, too, and allow their folks to contribute to the organizational goals.”
Recognizing Contributions Physician Personalities Make to the Greater Good
My family and I recently took a spring break trip out west to see a few national parks. During the trip, we stayed on a family ranch in Utah. It had a wide variety of livestock, including a large number of mules and horses.
During our stay at this family-owned ranch, two things really stood out and made me think:
- The guesthouse we stayed in had an inordinate volume of collections dedicated to the science and art of raising horses and mules. Everywhere one looked you could find a wall-mounted picture, poem, or coffee table book about these species. My favorite, written by the owner of the ranch, John Hauer, was The Natural Superiority of Mules.1
- The second thing I noticed was that every member of the ranch-owning family had fairly strong opinions about which was better—horse or mule. Just to recap the biology, a horse is the product of two horses, whereas a mule is the progeny of a male donkey and a female horse. It turns out that their physical structure and demeanors are very different.
One of the oldest members of the ranch family (who I believe was a “distant uncle”) had a very strong opinion about the superiority of the mule. His opinion was based on selected facts, including that mules are “steadier on their feet” in unstable ground, require less volume and less frequent food and water, and very rarely became ill or need costly veterinary care.
Another mule-favoring family member told us how mules get a “bad rap” for being stubborn when they actually are much smarter and better decision makers than horses. She recalled a famous folklore of a farmer who took his mule out to gather materials from across a field. When the farmer and the mule approached a wooden bridge, the mule absolutely refused to cross the bridge. After much back and forth between the farmer and the mule (involving both coaxing and cussing), the farmer gave up and returned to the farm with the mule. He then took his horse on the same errand. When they came to the same bridge, the horse also hesitated but required little bargaining from the farmer to coax it to cross the bridge. When barely halfway across, a rotten board in the bridge gave way, almost sending both the horse and the farmer to their deaths in the ravine below.
The moral of the folklore is that mules cannot be coaxed (or cussed) into performing behaviors that will put themselves or those around them at risk of injury or death. Mules will stop when exhausted or profoundly dehydrated, for example, whereas a horse will continue on if ordered by their farmer, even to the point of running themselves to their eventual demise.
One of the younger members of the family-owned ranch, however, had very strong opinions on the superiority of the horse. Horses are loyal and unwavering in their dedication to please those that they serve. They will put the needs of others before themselves in most situations and therefore almost always “outperform” a mule in all respects. They are willing and (usually) able to perform in uncertain conditions, even despite some reservations. They are loyal and loving, and they have unique and inquisitive personalities, which makes them fun to raise and to ride any day.
Test Drives
Our family of four went on a ride with some of these animals and randomly got two horses and two mules. Interestingly, during our ride, we all did indeed notice the differences between the horses and the mules.
The horses were seemingly easygoing and quick to please, easily following cues to change direction or course. The mules were more hesitant and seemed to need to understand why they were being asked to do something before they acquiesced to the demand.
And when we approached a narrow rocky downslope, the mules were slow, steady, and confident, whereas the horses were seemingly uncomfortable and less agile. And, indeed in researching mules, they seem to have gotten a very bad rap over time (as evidenced by the term “stubborn as a mule”).
Charles Darwin actually categorized mules as an example of “hybrid vigor,” which is a rare example of when an offspring is actually better in most ways than either of its parents. Compared to its parental species, mules have more intelligence, endurance, longevity, health, speed, height, and agility. Also to their advantage, they have harder skin and hooves, allowing them to weather and endure more treacherous conditions.
With all of this newfound knowledge of the mule, it struck me what remarkable similarity some physicians have with mules and the role that these mules are likely serving within our organizations. These physicians are probably labeled as stubborn, obstinate, resistant, or impatient. But maybe they are actually intelligent, agile, and appropriately cautious. Maybe the resistance they express in the organization is serving to warn others about the rotten wooden bridges.
HM Takeaway
Similar to a ranch, most hospitals probably function best with a healthy combination of horses and mules. So if you get an opportunity, next time you encounter physicians at your hospital acting like mules, you should congratulate them and appreciate their mule-like characteristics. Recognize the contribution these types of physicians are making, in their own way, to the greater good of the organization.
After all, we can’t—and shouldn’t—all be horses. TH
Reference
1. Hauer J. The Natural Superiority of Mules: A Celebration of One of the Most Intelligent, Sure-footed, and Misunderstood Animals in the World. New York, NY: Skyhorse Publishing; 2006.
My family and I recently took a spring break trip out west to see a few national parks. During the trip, we stayed on a family ranch in Utah. It had a wide variety of livestock, including a large number of mules and horses.
During our stay at this family-owned ranch, two things really stood out and made me think:
- The guesthouse we stayed in had an inordinate volume of collections dedicated to the science and art of raising horses and mules. Everywhere one looked you could find a wall-mounted picture, poem, or coffee table book about these species. My favorite, written by the owner of the ranch, John Hauer, was The Natural Superiority of Mules.1
- The second thing I noticed was that every member of the ranch-owning family had fairly strong opinions about which was better—horse or mule. Just to recap the biology, a horse is the product of two horses, whereas a mule is the progeny of a male donkey and a female horse. It turns out that their physical structure and demeanors are very different.
One of the oldest members of the ranch family (who I believe was a “distant uncle”) had a very strong opinion about the superiority of the mule. His opinion was based on selected facts, including that mules are “steadier on their feet” in unstable ground, require less volume and less frequent food and water, and very rarely became ill or need costly veterinary care.
Another mule-favoring family member told us how mules get a “bad rap” for being stubborn when they actually are much smarter and better decision makers than horses. She recalled a famous folklore of a farmer who took his mule out to gather materials from across a field. When the farmer and the mule approached a wooden bridge, the mule absolutely refused to cross the bridge. After much back and forth between the farmer and the mule (involving both coaxing and cussing), the farmer gave up and returned to the farm with the mule. He then took his horse on the same errand. When they came to the same bridge, the horse also hesitated but required little bargaining from the farmer to coax it to cross the bridge. When barely halfway across, a rotten board in the bridge gave way, almost sending both the horse and the farmer to their deaths in the ravine below.
The moral of the folklore is that mules cannot be coaxed (or cussed) into performing behaviors that will put themselves or those around them at risk of injury or death. Mules will stop when exhausted or profoundly dehydrated, for example, whereas a horse will continue on if ordered by their farmer, even to the point of running themselves to their eventual demise.
One of the younger members of the family-owned ranch, however, had very strong opinions on the superiority of the horse. Horses are loyal and unwavering in their dedication to please those that they serve. They will put the needs of others before themselves in most situations and therefore almost always “outperform” a mule in all respects. They are willing and (usually) able to perform in uncertain conditions, even despite some reservations. They are loyal and loving, and they have unique and inquisitive personalities, which makes them fun to raise and to ride any day.
Test Drives
Our family of four went on a ride with some of these animals and randomly got two horses and two mules. Interestingly, during our ride, we all did indeed notice the differences between the horses and the mules.
The horses were seemingly easygoing and quick to please, easily following cues to change direction or course. The mules were more hesitant and seemed to need to understand why they were being asked to do something before they acquiesced to the demand.
And when we approached a narrow rocky downslope, the mules were slow, steady, and confident, whereas the horses were seemingly uncomfortable and less agile. And, indeed in researching mules, they seem to have gotten a very bad rap over time (as evidenced by the term “stubborn as a mule”).
Charles Darwin actually categorized mules as an example of “hybrid vigor,” which is a rare example of when an offspring is actually better in most ways than either of its parents. Compared to its parental species, mules have more intelligence, endurance, longevity, health, speed, height, and agility. Also to their advantage, they have harder skin and hooves, allowing them to weather and endure more treacherous conditions.
With all of this newfound knowledge of the mule, it struck me what remarkable similarity some physicians have with mules and the role that these mules are likely serving within our organizations. These physicians are probably labeled as stubborn, obstinate, resistant, or impatient. But maybe they are actually intelligent, agile, and appropriately cautious. Maybe the resistance they express in the organization is serving to warn others about the rotten wooden bridges.
HM Takeaway
Similar to a ranch, most hospitals probably function best with a healthy combination of horses and mules. So if you get an opportunity, next time you encounter physicians at your hospital acting like mules, you should congratulate them and appreciate their mule-like characteristics. Recognize the contribution these types of physicians are making, in their own way, to the greater good of the organization.
After all, we can’t—and shouldn’t—all be horses. TH
Reference
1. Hauer J. The Natural Superiority of Mules: A Celebration of One of the Most Intelligent, Sure-footed, and Misunderstood Animals in the World. New York, NY: Skyhorse Publishing; 2006.
My family and I recently took a spring break trip out west to see a few national parks. During the trip, we stayed on a family ranch in Utah. It had a wide variety of livestock, including a large number of mules and horses.
During our stay at this family-owned ranch, two things really stood out and made me think:
- The guesthouse we stayed in had an inordinate volume of collections dedicated to the science and art of raising horses and mules. Everywhere one looked you could find a wall-mounted picture, poem, or coffee table book about these species. My favorite, written by the owner of the ranch, John Hauer, was The Natural Superiority of Mules.1
- The second thing I noticed was that every member of the ranch-owning family had fairly strong opinions about which was better—horse or mule. Just to recap the biology, a horse is the product of two horses, whereas a mule is the progeny of a male donkey and a female horse. It turns out that their physical structure and demeanors are very different.
One of the oldest members of the ranch family (who I believe was a “distant uncle”) had a very strong opinion about the superiority of the mule. His opinion was based on selected facts, including that mules are “steadier on their feet” in unstable ground, require less volume and less frequent food and water, and very rarely became ill or need costly veterinary care.
Another mule-favoring family member told us how mules get a “bad rap” for being stubborn when they actually are much smarter and better decision makers than horses. She recalled a famous folklore of a farmer who took his mule out to gather materials from across a field. When the farmer and the mule approached a wooden bridge, the mule absolutely refused to cross the bridge. After much back and forth between the farmer and the mule (involving both coaxing and cussing), the farmer gave up and returned to the farm with the mule. He then took his horse on the same errand. When they came to the same bridge, the horse also hesitated but required little bargaining from the farmer to coax it to cross the bridge. When barely halfway across, a rotten board in the bridge gave way, almost sending both the horse and the farmer to their deaths in the ravine below.
The moral of the folklore is that mules cannot be coaxed (or cussed) into performing behaviors that will put themselves or those around them at risk of injury or death. Mules will stop when exhausted or profoundly dehydrated, for example, whereas a horse will continue on if ordered by their farmer, even to the point of running themselves to their eventual demise.
One of the younger members of the family-owned ranch, however, had very strong opinions on the superiority of the horse. Horses are loyal and unwavering in their dedication to please those that they serve. They will put the needs of others before themselves in most situations and therefore almost always “outperform” a mule in all respects. They are willing and (usually) able to perform in uncertain conditions, even despite some reservations. They are loyal and loving, and they have unique and inquisitive personalities, which makes them fun to raise and to ride any day.
Test Drives
Our family of four went on a ride with some of these animals and randomly got two horses and two mules. Interestingly, during our ride, we all did indeed notice the differences between the horses and the mules.
The horses were seemingly easygoing and quick to please, easily following cues to change direction or course. The mules were more hesitant and seemed to need to understand why they were being asked to do something before they acquiesced to the demand.
And when we approached a narrow rocky downslope, the mules were slow, steady, and confident, whereas the horses were seemingly uncomfortable and less agile. And, indeed in researching mules, they seem to have gotten a very bad rap over time (as evidenced by the term “stubborn as a mule”).
Charles Darwin actually categorized mules as an example of “hybrid vigor,” which is a rare example of when an offspring is actually better in most ways than either of its parents. Compared to its parental species, mules have more intelligence, endurance, longevity, health, speed, height, and agility. Also to their advantage, they have harder skin and hooves, allowing them to weather and endure more treacherous conditions.
With all of this newfound knowledge of the mule, it struck me what remarkable similarity some physicians have with mules and the role that these mules are likely serving within our organizations. These physicians are probably labeled as stubborn, obstinate, resistant, or impatient. But maybe they are actually intelligent, agile, and appropriately cautious. Maybe the resistance they express in the organization is serving to warn others about the rotten wooden bridges.
HM Takeaway
Similar to a ranch, most hospitals probably function best with a healthy combination of horses and mules. So if you get an opportunity, next time you encounter physicians at your hospital acting like mules, you should congratulate them and appreciate their mule-like characteristics. Recognize the contribution these types of physicians are making, in their own way, to the greater good of the organization.
After all, we can’t—and shouldn’t—all be horses. TH
Reference
1. Hauer J. The Natural Superiority of Mules: A Celebration of One of the Most Intelligent, Sure-footed, and Misunderstood Animals in the World. New York, NY: Skyhorse Publishing; 2006.
Does U.S. Healthcare Need More Diverse Leadership?
Throughout its history, the United States has been a nation of immigrants. From the early colonial settlements to the mid-20th century, most immigrants came from Western European countries. Since 1965, when the Immigration and Nationality Act abolished national-origin quotas, the diversity of immigrants has increased. “By the year 2043,” says Tomás León, president and CEO of the Institute for Diversity in Health Management in Chicago, “we will be a country where the majority of our population is comprised of racial and ethnic minorities.”
Those changing demographics, cited from the U.S. Census Bureau’s projections, already are evidenced in hospital patient populations. According to a benchmarking survey sponsored by the institute, which is an affiliate of the American Hospital Association, the percentage of minority patients seen in hospitals grew from 29% to 31% of patient census between 2011 and 2013.1 And yet, the survey found this increasing diversity is not currently reflected in leadership positions. During the same time period, underrepresented racial and ethnic minorities (UREM) on hospital boards of directors (14%) and in C-suite positions (14%) remained flat (see Figure 1).
Gender disparities in healthcare and academic leadership also have been slow to change. Periodic surveys conducted by the American College of Healthcare Executives indicate that women comprise only 11% of healthcare CEOs in the U.S.2 And despite the fact that women make up half of all medical students (and one-third of full-time faculty), the Association of American Medical Colleges (AAMC) finds that women still trail men when it comes to attaining full professorship and decanal positions at their academic institutions.3
The Hospitalist interviewed medical directors, researchers, diversity management professionals, and hospitalists to ascertain current solutions being pursued to narrow the gaps in leadership diversity.
Why Diversity in Leadership Matters
Eric E. Howell, MD, MHM, chief of the Division of Hospital Medicine at Johns Hopkins Bayview Medical Center in the Hopkins School of Medicine in Baltimore, believes there is a need to encourage the advancement to leadership positions for female and UREM physicians.
“In medicine, it’s really about service. If we are really here for our patients, we need representation of diversity in our faculty and leadership,” says Dr. Howell, a past SHM president and faculty member of SHM’s Leadership Academy since its inception in 2005. In addition, he says, “Diversity adds incredible strength to an organization and adds to the richness of the ideas and solutions to overcome challenging problems.”
With the implementation of the Affordable Care Act, formerly uninsured people are now accessing the healthcare system; many are bilingual and bicultural, notes George A. Zeppenfeldt-Cestero, president and CEO, Association of Hispanic Healthcare Executives.
“You want to make sure that providers, whether they are physicians, nurses, dentists, or health executives that drive policy issues, are also reflective of that population throughout the organization,” he says. “The real definition of diversity is making sure you have diversity in all layers of the workforce, including the C-suite.”
León points to the coming “seismic demographic shifts” and wonders if healthcare is ready to become more reflective of the communities it serves.
“Increasing diversity in healthcare leadership and governance is essential for the delivery and provision of culturally competent care,” León says. “Now, more than ever, it’s important that we collectively accelerate progress in this area.”
Advancing in Academic and Hospital Medicine
Might hospital medicine offer additional opportunities for women and minorities to advance into leadership positions? Hospitalist Flora Kisuule, MD, SFHM, assistant professor of medicine at Johns Hopkins School of Medicine and associate division director of the Collaborative Inpatient Medicine Service (CIMS) at Johns Hopkins Bayview Medical Center, believes this may be the case. She was with Dr. Howell’s group when he needed to fill the associate director position.
“My advancement speaks to hospital medicine and the fact that we are growing as a field,” she says. “Because of that, opportunities are presenting themselves.”
Dr. Kisuule’s ability to thrive in her position speaks to her professionalism but also to a number of other intentional factors: Dr. Howell’s continuing sponsorship to include her in leadership opportunities, an emergency call system for parents with sick children, and a women’s task force whose agenda calls for transparency in hiring and advancement.
Intentional Structure Change
Cardiologist Hannah A. Valantine, MD, recognizes the importance of addressing the lack of women and people from unrepresented groups in the Science, Technology, Engineering, and Mathematics (STEM) workforce. While at Stanford University School of Medicine, she developed and put into place a set of strategies to understand and mitigate the drivers of gender imbalance. Since then, Dr. Valantine was recruited to bring her expertise to the National Institutes of Health in Bethesda, Md., where she is the inaugural chief officer for scientific workforce diversity. In this role, she is committed “to promoting biomedical workforce diversity as an opportunity, not a problem.”
Dr. Valantine is pushing NIH to pursue a wide range of evidence-based programming to eliminate career-transition barriers that keep women and individuals from underrepresented groups from attaining spots in the top echelons of science and health leadership. She believes that applying scientific rigor to the issue of workforce diversity can lead to quantifiable, translatable, and repeatable methods for recruitment and retention of talent in the biomedical workforce (see “Building Blocks").
Before joining NIH, Dr. Valantine and her colleagues at Stanford surveyed gender composition and faculty satisfaction several years after initiating a multifaceted intervention to boost recruitment and development of women faculty.4 After making a visible commitment of resources to support faculty, with special attention to women, Stanford rose from below to above national benchmarks in the representation of women among faculty. Yet significant work remains to be done, Dr. Valantine says. Her work predicts that the estimated time to achieve 50% occupancy of full professorships by women nationally approaches 50 years—“far too long using current approaches.”
In a separate review article, Dr. Valantine and co-author Christy Sandborg, MD, described the Stanford University School of Medicine Academic Biomedical Career Customization (ABCC) model, which was adapted from Deloitte’s Mass Career Customization framework and allows for development of individual career plans that span a faculty member’s total career, not just a year or two at a time. Long-term planning can enable better alignment between the work culture and values of the workforce, which will improve the outlook for women faculty, Dr. Valantine says.
The issues of work-life balance may actually be generational, Dr. Valantine explains. Veteran hospitalist Janet Nagamine, MD, BSN, SFHM, of Santa Clara, Calif., agrees.
“Nowadays, men as well as women are looking for work-life balance,” she says.
In hospital medicine, Dr. Nagamine points out, the structural changes required to effect a work-life balance for hospital leaders are often difficult to achieve.
“As productivity surveys show, HM group leaders are putting in as many RVUs as the staff,” the former SHM board member says. “There is no dedicated time for administrative duties.”
Construct a Pipeline
Barriers to advancement often are particular to characteristics of diverse populations. For example, the AAMC’s report on the U.S. physician workforce documents that in African-American physicians 40 and younger, women outnumber their male counterparts. Therefore, in the association’s Diversity in Medical Education: Facts and Figures 2012 report, the executive summary points out the need to strengthen the medical education pipeline to increase the number of African-American males who enter the premed track.
Despite the fast-growing percentage of Latino and Hispanic populations in the United States, the shortage of Latino/Hispanic physicians increased from 1980 to 2010. Latinos/Hispanics are greatly underrepresented in the medical student, resident, and faculty populations, according to John Paul Sánchez, MD, MPH, assistant dean for diversity and inclusion in the Office for Diversity and Community Engagement at Rutgers, The State University of New Jersey. Likewise, Zeppenfeldt-Cestero believes that efforts must begin much earlier with Latino and other minority and underrepresented students.
“We have to make sure our students pursue the STEM disciplines and that they also later have the education and preparation to be competitive at the MBA or MPH levels,” he says.
Dr. Sánchez, an associate professor of emergency medicine and a diversity activist since his med school days, is the recipient of last year’s Association of Hispanic Healthcare Executives’ academic leader of the year award. Since September 2014, he has been involved with Building the Next Generation of Academic Physicians Inc., which collaborates with more than 40 medical schools across the country. The initiative offers conferences designed to develop diverse medical students’ and residents’ interest in pursuing academic medicine. Open to all medical students and residents, the conference curriculum is tailored for women, UREMs, and trainees who identify as lesbian, gay, bisexual, or transgender (LGBT), he says. Seven conferences were held in 2015, 10 are planned for this year, and seven for 2017.
Healthcare Leadership Gaps
Despite their omnipresence in healthcare, there is a dearth of women in chief executive and governance roles, as has been noted by both the American College of Healthcare Executives and the National Center for Healthcare Leadership. As with academic leadership positions, the leadership gap in the administrative sector does not seem to be due to a lack of women entering graduate programs in health administration. On the contrary, since the mid-1980s women have comprised 50% to 60% of graduate students.
“This is absolutely not a pipeline issue,” says Christy Harris Lemak, PhD, FACHE, professor and chair of the Department of Health Services Administration at the University of Alabama at Birmingham School of Health Professions and lead investigator of the National Center for Healthcare Leadership’s study of women in healthcare executive positions. Other factors come into play.
In the study, she and her co-authors queried female healthcare CEOs to ascertain the critical career inflection points that led to their success.6 Those who were strategic about their careers, sought out mentors, and voiced their intentions about pursuing leadership positions were more likely to be successful in those efforts. However, individual career efforts must be coupled with overall organizational commitment to fostering inclusion (see “Path to the Top: Strategic Advice for Women").
Hospitals and healthcare organizations must pursue the development of human capital (and the diversity of their leaders) in a systematic way. “We recommended [in the study] that organizations set expectations that leaders who mentor other potential leaders be rewarded in the same way as those who hit financial targets or readmission rate targets,” Dr. Lemak says.
Leadership matters, agrees Deborah J. Bowen, FACHE, CAE, president and CEO of Chicago-based American College of Healthcare Executives.
“I think we’re getting a little smarter. Organizational leaders and trustees have a better understanding that talent development is one of the most important jobs,” she says. “If you don’t have the right people in the right places making good decisions on behalf of the patients and the populations in the communities they’re serving, the rest falls apart.”
Nuances of Mentoring
Many conversations about encouraging diversity in healthcare leadership converge around the role of effective mentoring and sponsorship. A substantial body of research supports the impact of mentoring on retention, research productivity, career satisfaction, and career development for women. It’s important to ensure that the institutional culture is geared toward mentoring junior faculty, says Jessie Kimbrough Marshall, MD, MPH, assistant professor in the Division of General Medicine Hospitalist Program at the University of Michigan Health System in Ann Arbor (UMHS).
Several of our sources pointed out that leaders must learn how to be effective mentors. More attention is being given to enhancing leaders’ mentorship skills. One example is at the Institute for Diversity in Health Management, which conducts an intensive 12-month certificate in diversity management program for practitioners. León says the program fosters ongoing networking and support through the American Leadership Council on Diversity in Healthcare by building leadership competencies.
Dr. Valantine points out that mentoring is hardly a one-style-fits-all proposition but that it is a crucial element to creating and retaining diversity. She says it should be viewed “much more broadly than it is today, and it should focus beyond the trainer-trainee relationship.”
The process is a two-way street. Denege Ward, MD, hospitalist, assistant professor of internal medicine, and director of the medical short stay unit at UMHS, says minorities need to be ready to take a leap of faith.
“Underrepresented faculty and staff should take the risk of possible failure in challenging situations but learn from it and do better and not succumb to fear in face of challenges,” Dr. Ward says.
Although mentoring is one important component in building diversity in academic medicine, Dr. Sánchez asserts that role models, champions, and sponsors are equally important.
“In addition and separate from role models, there must be in place policies and procedures that promote a climate for diverse individuals to succeed,” he says. “What’s needed is an institutional vision and strategic plan that recognizes the importance of diversity. [It] has to become a core principle.”
Dr. Marshall echoes that refrain, noting the recruitment and retention of a diverse set of leaders will take time and intentionality. She is actively engaged in organizing annual meeting mentoring panels at the Society of General Internal Medicine.
“There are still quite a few barriers for women and minorities to advance into hospital leadership roles,” she says. “We still have a long way to go. However, I’m seeing more women and people of color get into these positions. The numbers are increasing, and that encourages me.” TH
Gretchen Henkel is a freelance writer in California.
References
- Institute for Diversity in Health Management. The state of health care diversity and disparities: a benchmarking study of U.S. hospitals. Available at: http://www.diversityconnection.org/diversityconnection/leadership-conferences/Benchmarking-Survey.jsp?fll=S11.
- Top issues confronting hospitals in 2015. American College of Healthcare Executives website. Available at: https://www.ache.org/pubs/research/ceoissues.cfm. Accessed March 5, 2016.
- Association of American Medical Colleges. Diversity in the physician workforce: facts & figures 2014. Available at: http://aamcdiversityfactsandfigures.org/.
- Valantine HA, Grewal D, Ku MC, et al. The gender gap in academic medicine: comparing results from a multifaceted intervention for Stanford faculty to peer and national cohorts. Acad Med. 2014;89(6):904-911.
- Valantine H, Sandborg CI. Changing the culture of academic medicine to eliminate the gender leadership gap: 50/50 by 2020. Acad Med. 2013;88(10):1411-1413.
- Sexton DW, Lemak CH, Wainio JA. Career inflection points of women who successfully achieved the hospital CEO position. J Healthc Manag. 2014;59(5):367-383.
Path to the Top: Strategic Advice for Women
One of the cornerstones of career advancement in healthcare is to stay connected by networking and attending meetings. For women and minorities, the path to leadership may not fit into the traditional linear model of the career ladder.
“For many leadership roles, you have to be visual and present; you have to attend meetings and functions,” says Denege Ward, MD, hospitalist, assistant professor of internal medicine, and director of the medical short stay unit at the University of Michigan Health System in Ann Arbor. “For women, this is difficult. We are still in charge of families and home.”
For some women, it may be more productive to employ the notion of the “leadership labyrinth.” Others refer to a “career lattice” or employ Deloitte’s Mass Career Customization framework.
“For women, the trajectory may include working part-time while their children are small or finding local training opportunities,” says Christy Harris Lemak, PhD, FACHE, professor and chair of the Department of Health Services Administration at the University of Alabama at Birmingham School of Health Professions and lead investigator of the National Center for Healthcare Leadership’s study of women in healthcare executive positions.
Hospitalist Flora Kisuule, MD, assistant professor of medicine at Johns Hopkins School of Medicine and associate division director of the Collaborative Inpatient Medicine Service (CIMS) at Johns Hopkins Bayview Medical Center in Baltimore, is a wife and mother of a 4-year-old. She agrees the leadership path for moms can take unexpected detours. She’s been able to complete some of her administrative tasks at home through the support of her medical director. If pursuing an MBA is too daunting, she encourages her hospitalist peers to take advantage of short courses and programs in leadership.
“As women, we like to do for others,” notes Elizabeth Gundersen, MD, FHM, assistant professor of clinical biomedical sciences at the Charles E. Schmidt College of Medicine at Florida Atlantic University in Boca Raton. While at the University of Massachusetts, she was one of eight physician quality officers and associate division chief of hospital medicine. To counter the impulse to say yes to everything, including roles that distract from ultimate career goals, one of the women leaders at UMass encouraged her mentees to “think of your ideal position—and then when a position is offered, assess that against your criteria.”
Jessie Kimbrough Marshall, MD, MPH, assistant professor in the Division of General Medicine Hospitalist Program at the University of Michigan Health System, seconds that opinion.
“Try to avoid professional commitments and activities that are not aligned to your career trajectory,” Dr. Marshall advises. “You can also identify someone who is in a position that is close to what you envision for yourself and reach out to that person.”
—Gretchen Henkel
Building Blocks: NIH’s Commitment to Enhance Diversity
The National Institutes of Health (NIH) has been committed to enhancing diversity for decades, according to cardiologist Hannah A. Valantine, MD.
“NIH has made considerable investments in programming,” says Dr. Valantine. However, despite these investments, “the change has not been as rapid or sustainable as we would like it to be.”
As a first step, in October 2014, NIH announced a new set of initiatives designed to enhance the ways in which participants are engaged and trained. Three components comprise the Enhancing Diversity in the NIH-Funded Workforce program. The Building Infrastructure Leading to Diversity (BUILD) program was awarded to 10 universities that met eligibility criteria for being under-resourced. The National Research Mentoring Network (NRMN) will recruit mentors and use methods (such as “train the trainer”) to bring a more deliberate and intentional approach to cultivating mentors. The third component, the Coordinating and Evaluation Center (CEC), focuses on evaluation and dissemination of identified best practices and competencies.
“We are moving away from the assumption that just because you are a leader in your research field that that means you are a good mentor,” Dr. Valantine says.
Throughout its history, the United States has been a nation of immigrants. From the early colonial settlements to the mid-20th century, most immigrants came from Western European countries. Since 1965, when the Immigration and Nationality Act abolished national-origin quotas, the diversity of immigrants has increased. “By the year 2043,” says Tomás León, president and CEO of the Institute for Diversity in Health Management in Chicago, “we will be a country where the majority of our population is comprised of racial and ethnic minorities.”
Those changing demographics, cited from the U.S. Census Bureau’s projections, already are evidenced in hospital patient populations. According to a benchmarking survey sponsored by the institute, which is an affiliate of the American Hospital Association, the percentage of minority patients seen in hospitals grew from 29% to 31% of patient census between 2011 and 2013.1 And yet, the survey found this increasing diversity is not currently reflected in leadership positions. During the same time period, underrepresented racial and ethnic minorities (UREM) on hospital boards of directors (14%) and in C-suite positions (14%) remained flat (see Figure 1).
Gender disparities in healthcare and academic leadership also have been slow to change. Periodic surveys conducted by the American College of Healthcare Executives indicate that women comprise only 11% of healthcare CEOs in the U.S.2 And despite the fact that women make up half of all medical students (and one-third of full-time faculty), the Association of American Medical Colleges (AAMC) finds that women still trail men when it comes to attaining full professorship and decanal positions at their academic institutions.3
The Hospitalist interviewed medical directors, researchers, diversity management professionals, and hospitalists to ascertain current solutions being pursued to narrow the gaps in leadership diversity.
Why Diversity in Leadership Matters
Eric E. Howell, MD, MHM, chief of the Division of Hospital Medicine at Johns Hopkins Bayview Medical Center in the Hopkins School of Medicine in Baltimore, believes there is a need to encourage the advancement to leadership positions for female and UREM physicians.
“In medicine, it’s really about service. If we are really here for our patients, we need representation of diversity in our faculty and leadership,” says Dr. Howell, a past SHM president and faculty member of SHM’s Leadership Academy since its inception in 2005. In addition, he says, “Diversity adds incredible strength to an organization and adds to the richness of the ideas and solutions to overcome challenging problems.”
With the implementation of the Affordable Care Act, formerly uninsured people are now accessing the healthcare system; many are bilingual and bicultural, notes George A. Zeppenfeldt-Cestero, president and CEO, Association of Hispanic Healthcare Executives.
“You want to make sure that providers, whether they are physicians, nurses, dentists, or health executives that drive policy issues, are also reflective of that population throughout the organization,” he says. “The real definition of diversity is making sure you have diversity in all layers of the workforce, including the C-suite.”
León points to the coming “seismic demographic shifts” and wonders if healthcare is ready to become more reflective of the communities it serves.
“Increasing diversity in healthcare leadership and governance is essential for the delivery and provision of culturally competent care,” León says. “Now, more than ever, it’s important that we collectively accelerate progress in this area.”
Advancing in Academic and Hospital Medicine
Might hospital medicine offer additional opportunities for women and minorities to advance into leadership positions? Hospitalist Flora Kisuule, MD, SFHM, assistant professor of medicine at Johns Hopkins School of Medicine and associate division director of the Collaborative Inpatient Medicine Service (CIMS) at Johns Hopkins Bayview Medical Center, believes this may be the case. She was with Dr. Howell’s group when he needed to fill the associate director position.
“My advancement speaks to hospital medicine and the fact that we are growing as a field,” she says. “Because of that, opportunities are presenting themselves.”
Dr. Kisuule’s ability to thrive in her position speaks to her professionalism but also to a number of other intentional factors: Dr. Howell’s continuing sponsorship to include her in leadership opportunities, an emergency call system for parents with sick children, and a women’s task force whose agenda calls for transparency in hiring and advancement.
Intentional Structure Change
Cardiologist Hannah A. Valantine, MD, recognizes the importance of addressing the lack of women and people from unrepresented groups in the Science, Technology, Engineering, and Mathematics (STEM) workforce. While at Stanford University School of Medicine, she developed and put into place a set of strategies to understand and mitigate the drivers of gender imbalance. Since then, Dr. Valantine was recruited to bring her expertise to the National Institutes of Health in Bethesda, Md., where she is the inaugural chief officer for scientific workforce diversity. In this role, she is committed “to promoting biomedical workforce diversity as an opportunity, not a problem.”
Dr. Valantine is pushing NIH to pursue a wide range of evidence-based programming to eliminate career-transition barriers that keep women and individuals from underrepresented groups from attaining spots in the top echelons of science and health leadership. She believes that applying scientific rigor to the issue of workforce diversity can lead to quantifiable, translatable, and repeatable methods for recruitment and retention of talent in the biomedical workforce (see “Building Blocks").
Before joining NIH, Dr. Valantine and her colleagues at Stanford surveyed gender composition and faculty satisfaction several years after initiating a multifaceted intervention to boost recruitment and development of women faculty.4 After making a visible commitment of resources to support faculty, with special attention to women, Stanford rose from below to above national benchmarks in the representation of women among faculty. Yet significant work remains to be done, Dr. Valantine says. Her work predicts that the estimated time to achieve 50% occupancy of full professorships by women nationally approaches 50 years—“far too long using current approaches.”
In a separate review article, Dr. Valantine and co-author Christy Sandborg, MD, described the Stanford University School of Medicine Academic Biomedical Career Customization (ABCC) model, which was adapted from Deloitte’s Mass Career Customization framework and allows for development of individual career plans that span a faculty member’s total career, not just a year or two at a time. Long-term planning can enable better alignment between the work culture and values of the workforce, which will improve the outlook for women faculty, Dr. Valantine says.
The issues of work-life balance may actually be generational, Dr. Valantine explains. Veteran hospitalist Janet Nagamine, MD, BSN, SFHM, of Santa Clara, Calif., agrees.
“Nowadays, men as well as women are looking for work-life balance,” she says.
In hospital medicine, Dr. Nagamine points out, the structural changes required to effect a work-life balance for hospital leaders are often difficult to achieve.
“As productivity surveys show, HM group leaders are putting in as many RVUs as the staff,” the former SHM board member says. “There is no dedicated time for administrative duties.”
Construct a Pipeline
Barriers to advancement often are particular to characteristics of diverse populations. For example, the AAMC’s report on the U.S. physician workforce documents that in African-American physicians 40 and younger, women outnumber their male counterparts. Therefore, in the association’s Diversity in Medical Education: Facts and Figures 2012 report, the executive summary points out the need to strengthen the medical education pipeline to increase the number of African-American males who enter the premed track.
Despite the fast-growing percentage of Latino and Hispanic populations in the United States, the shortage of Latino/Hispanic physicians increased from 1980 to 2010. Latinos/Hispanics are greatly underrepresented in the medical student, resident, and faculty populations, according to John Paul Sánchez, MD, MPH, assistant dean for diversity and inclusion in the Office for Diversity and Community Engagement at Rutgers, The State University of New Jersey. Likewise, Zeppenfeldt-Cestero believes that efforts must begin much earlier with Latino and other minority and underrepresented students.
“We have to make sure our students pursue the STEM disciplines and that they also later have the education and preparation to be competitive at the MBA or MPH levels,” he says.
Dr. Sánchez, an associate professor of emergency medicine and a diversity activist since his med school days, is the recipient of last year’s Association of Hispanic Healthcare Executives’ academic leader of the year award. Since September 2014, he has been involved with Building the Next Generation of Academic Physicians Inc., which collaborates with more than 40 medical schools across the country. The initiative offers conferences designed to develop diverse medical students’ and residents’ interest in pursuing academic medicine. Open to all medical students and residents, the conference curriculum is tailored for women, UREMs, and trainees who identify as lesbian, gay, bisexual, or transgender (LGBT), he says. Seven conferences were held in 2015, 10 are planned for this year, and seven for 2017.
Healthcare Leadership Gaps
Despite their omnipresence in healthcare, there is a dearth of women in chief executive and governance roles, as has been noted by both the American College of Healthcare Executives and the National Center for Healthcare Leadership. As with academic leadership positions, the leadership gap in the administrative sector does not seem to be due to a lack of women entering graduate programs in health administration. On the contrary, since the mid-1980s women have comprised 50% to 60% of graduate students.
“This is absolutely not a pipeline issue,” says Christy Harris Lemak, PhD, FACHE, professor and chair of the Department of Health Services Administration at the University of Alabama at Birmingham School of Health Professions and lead investigator of the National Center for Healthcare Leadership’s study of women in healthcare executive positions. Other factors come into play.
In the study, she and her co-authors queried female healthcare CEOs to ascertain the critical career inflection points that led to their success.6 Those who were strategic about their careers, sought out mentors, and voiced their intentions about pursuing leadership positions were more likely to be successful in those efforts. However, individual career efforts must be coupled with overall organizational commitment to fostering inclusion (see “Path to the Top: Strategic Advice for Women").
Hospitals and healthcare organizations must pursue the development of human capital (and the diversity of their leaders) in a systematic way. “We recommended [in the study] that organizations set expectations that leaders who mentor other potential leaders be rewarded in the same way as those who hit financial targets or readmission rate targets,” Dr. Lemak says.
Leadership matters, agrees Deborah J. Bowen, FACHE, CAE, president and CEO of Chicago-based American College of Healthcare Executives.
“I think we’re getting a little smarter. Organizational leaders and trustees have a better understanding that talent development is one of the most important jobs,” she says. “If you don’t have the right people in the right places making good decisions on behalf of the patients and the populations in the communities they’re serving, the rest falls apart.”
Nuances of Mentoring
Many conversations about encouraging diversity in healthcare leadership converge around the role of effective mentoring and sponsorship. A substantial body of research supports the impact of mentoring on retention, research productivity, career satisfaction, and career development for women. It’s important to ensure that the institutional culture is geared toward mentoring junior faculty, says Jessie Kimbrough Marshall, MD, MPH, assistant professor in the Division of General Medicine Hospitalist Program at the University of Michigan Health System in Ann Arbor (UMHS).
Several of our sources pointed out that leaders must learn how to be effective mentors. More attention is being given to enhancing leaders’ mentorship skills. One example is at the Institute for Diversity in Health Management, which conducts an intensive 12-month certificate in diversity management program for practitioners. León says the program fosters ongoing networking and support through the American Leadership Council on Diversity in Healthcare by building leadership competencies.
Dr. Valantine points out that mentoring is hardly a one-style-fits-all proposition but that it is a crucial element to creating and retaining diversity. She says it should be viewed “much more broadly than it is today, and it should focus beyond the trainer-trainee relationship.”
The process is a two-way street. Denege Ward, MD, hospitalist, assistant professor of internal medicine, and director of the medical short stay unit at UMHS, says minorities need to be ready to take a leap of faith.
“Underrepresented faculty and staff should take the risk of possible failure in challenging situations but learn from it and do better and not succumb to fear in face of challenges,” Dr. Ward says.
Although mentoring is one important component in building diversity in academic medicine, Dr. Sánchez asserts that role models, champions, and sponsors are equally important.
“In addition and separate from role models, there must be in place policies and procedures that promote a climate for diverse individuals to succeed,” he says. “What’s needed is an institutional vision and strategic plan that recognizes the importance of diversity. [It] has to become a core principle.”
Dr. Marshall echoes that refrain, noting the recruitment and retention of a diverse set of leaders will take time and intentionality. She is actively engaged in organizing annual meeting mentoring panels at the Society of General Internal Medicine.
“There are still quite a few barriers for women and minorities to advance into hospital leadership roles,” she says. “We still have a long way to go. However, I’m seeing more women and people of color get into these positions. The numbers are increasing, and that encourages me.” TH
Gretchen Henkel is a freelance writer in California.
References
- Institute for Diversity in Health Management. The state of health care diversity and disparities: a benchmarking study of U.S. hospitals. Available at: http://www.diversityconnection.org/diversityconnection/leadership-conferences/Benchmarking-Survey.jsp?fll=S11.
- Top issues confronting hospitals in 2015. American College of Healthcare Executives website. Available at: https://www.ache.org/pubs/research/ceoissues.cfm. Accessed March 5, 2016.
- Association of American Medical Colleges. Diversity in the physician workforce: facts & figures 2014. Available at: http://aamcdiversityfactsandfigures.org/.
- Valantine HA, Grewal D, Ku MC, et al. The gender gap in academic medicine: comparing results from a multifaceted intervention for Stanford faculty to peer and national cohorts. Acad Med. 2014;89(6):904-911.
- Valantine H, Sandborg CI. Changing the culture of academic medicine to eliminate the gender leadership gap: 50/50 by 2020. Acad Med. 2013;88(10):1411-1413.
- Sexton DW, Lemak CH, Wainio JA. Career inflection points of women who successfully achieved the hospital CEO position. J Healthc Manag. 2014;59(5):367-383.
Path to the Top: Strategic Advice for Women
One of the cornerstones of career advancement in healthcare is to stay connected by networking and attending meetings. For women and minorities, the path to leadership may not fit into the traditional linear model of the career ladder.
“For many leadership roles, you have to be visual and present; you have to attend meetings and functions,” says Denege Ward, MD, hospitalist, assistant professor of internal medicine, and director of the medical short stay unit at the University of Michigan Health System in Ann Arbor. “For women, this is difficult. We are still in charge of families and home.”
For some women, it may be more productive to employ the notion of the “leadership labyrinth.” Others refer to a “career lattice” or employ Deloitte’s Mass Career Customization framework.
“For women, the trajectory may include working part-time while their children are small or finding local training opportunities,” says Christy Harris Lemak, PhD, FACHE, professor and chair of the Department of Health Services Administration at the University of Alabama at Birmingham School of Health Professions and lead investigator of the National Center for Healthcare Leadership’s study of women in healthcare executive positions.
Hospitalist Flora Kisuule, MD, assistant professor of medicine at Johns Hopkins School of Medicine and associate division director of the Collaborative Inpatient Medicine Service (CIMS) at Johns Hopkins Bayview Medical Center in Baltimore, is a wife and mother of a 4-year-old. She agrees the leadership path for moms can take unexpected detours. She’s been able to complete some of her administrative tasks at home through the support of her medical director. If pursuing an MBA is too daunting, she encourages her hospitalist peers to take advantage of short courses and programs in leadership.
“As women, we like to do for others,” notes Elizabeth Gundersen, MD, FHM, assistant professor of clinical biomedical sciences at the Charles E. Schmidt College of Medicine at Florida Atlantic University in Boca Raton. While at the University of Massachusetts, she was one of eight physician quality officers and associate division chief of hospital medicine. To counter the impulse to say yes to everything, including roles that distract from ultimate career goals, one of the women leaders at UMass encouraged her mentees to “think of your ideal position—and then when a position is offered, assess that against your criteria.”
Jessie Kimbrough Marshall, MD, MPH, assistant professor in the Division of General Medicine Hospitalist Program at the University of Michigan Health System, seconds that opinion.
“Try to avoid professional commitments and activities that are not aligned to your career trajectory,” Dr. Marshall advises. “You can also identify someone who is in a position that is close to what you envision for yourself and reach out to that person.”
—Gretchen Henkel
Building Blocks: NIH’s Commitment to Enhance Diversity
The National Institutes of Health (NIH) has been committed to enhancing diversity for decades, according to cardiologist Hannah A. Valantine, MD.
“NIH has made considerable investments in programming,” says Dr. Valantine. However, despite these investments, “the change has not been as rapid or sustainable as we would like it to be.”
As a first step, in October 2014, NIH announced a new set of initiatives designed to enhance the ways in which participants are engaged and trained. Three components comprise the Enhancing Diversity in the NIH-Funded Workforce program. The Building Infrastructure Leading to Diversity (BUILD) program was awarded to 10 universities that met eligibility criteria for being under-resourced. The National Research Mentoring Network (NRMN) will recruit mentors and use methods (such as “train the trainer”) to bring a more deliberate and intentional approach to cultivating mentors. The third component, the Coordinating and Evaluation Center (CEC), focuses on evaluation and dissemination of identified best practices and competencies.
“We are moving away from the assumption that just because you are a leader in your research field that that means you are a good mentor,” Dr. Valantine says.
Throughout its history, the United States has been a nation of immigrants. From the early colonial settlements to the mid-20th century, most immigrants came from Western European countries. Since 1965, when the Immigration and Nationality Act abolished national-origin quotas, the diversity of immigrants has increased. “By the year 2043,” says Tomás León, president and CEO of the Institute for Diversity in Health Management in Chicago, “we will be a country where the majority of our population is comprised of racial and ethnic minorities.”
Those changing demographics, cited from the U.S. Census Bureau’s projections, already are evidenced in hospital patient populations. According to a benchmarking survey sponsored by the institute, which is an affiliate of the American Hospital Association, the percentage of minority patients seen in hospitals grew from 29% to 31% of patient census between 2011 and 2013.1 And yet, the survey found this increasing diversity is not currently reflected in leadership positions. During the same time period, underrepresented racial and ethnic minorities (UREM) on hospital boards of directors (14%) and in C-suite positions (14%) remained flat (see Figure 1).
Gender disparities in healthcare and academic leadership also have been slow to change. Periodic surveys conducted by the American College of Healthcare Executives indicate that women comprise only 11% of healthcare CEOs in the U.S.2 And despite the fact that women make up half of all medical students (and one-third of full-time faculty), the Association of American Medical Colleges (AAMC) finds that women still trail men when it comes to attaining full professorship and decanal positions at their academic institutions.3
The Hospitalist interviewed medical directors, researchers, diversity management professionals, and hospitalists to ascertain current solutions being pursued to narrow the gaps in leadership diversity.
Why Diversity in Leadership Matters
Eric E. Howell, MD, MHM, chief of the Division of Hospital Medicine at Johns Hopkins Bayview Medical Center in the Hopkins School of Medicine in Baltimore, believes there is a need to encourage the advancement to leadership positions for female and UREM physicians.
“In medicine, it’s really about service. If we are really here for our patients, we need representation of diversity in our faculty and leadership,” says Dr. Howell, a past SHM president and faculty member of SHM’s Leadership Academy since its inception in 2005. In addition, he says, “Diversity adds incredible strength to an organization and adds to the richness of the ideas and solutions to overcome challenging problems.”
With the implementation of the Affordable Care Act, formerly uninsured people are now accessing the healthcare system; many are bilingual and bicultural, notes George A. Zeppenfeldt-Cestero, president and CEO, Association of Hispanic Healthcare Executives.
“You want to make sure that providers, whether they are physicians, nurses, dentists, or health executives that drive policy issues, are also reflective of that population throughout the organization,” he says. “The real definition of diversity is making sure you have diversity in all layers of the workforce, including the C-suite.”
León points to the coming “seismic demographic shifts” and wonders if healthcare is ready to become more reflective of the communities it serves.
“Increasing diversity in healthcare leadership and governance is essential for the delivery and provision of culturally competent care,” León says. “Now, more than ever, it’s important that we collectively accelerate progress in this area.”
Advancing in Academic and Hospital Medicine
Might hospital medicine offer additional opportunities for women and minorities to advance into leadership positions? Hospitalist Flora Kisuule, MD, SFHM, assistant professor of medicine at Johns Hopkins School of Medicine and associate division director of the Collaborative Inpatient Medicine Service (CIMS) at Johns Hopkins Bayview Medical Center, believes this may be the case. She was with Dr. Howell’s group when he needed to fill the associate director position.
“My advancement speaks to hospital medicine and the fact that we are growing as a field,” she says. “Because of that, opportunities are presenting themselves.”
Dr. Kisuule’s ability to thrive in her position speaks to her professionalism but also to a number of other intentional factors: Dr. Howell’s continuing sponsorship to include her in leadership opportunities, an emergency call system for parents with sick children, and a women’s task force whose agenda calls for transparency in hiring and advancement.
Intentional Structure Change
Cardiologist Hannah A. Valantine, MD, recognizes the importance of addressing the lack of women and people from unrepresented groups in the Science, Technology, Engineering, and Mathematics (STEM) workforce. While at Stanford University School of Medicine, she developed and put into place a set of strategies to understand and mitigate the drivers of gender imbalance. Since then, Dr. Valantine was recruited to bring her expertise to the National Institutes of Health in Bethesda, Md., where she is the inaugural chief officer for scientific workforce diversity. In this role, she is committed “to promoting biomedical workforce diversity as an opportunity, not a problem.”
Dr. Valantine is pushing NIH to pursue a wide range of evidence-based programming to eliminate career-transition barriers that keep women and individuals from underrepresented groups from attaining spots in the top echelons of science and health leadership. She believes that applying scientific rigor to the issue of workforce diversity can lead to quantifiable, translatable, and repeatable methods for recruitment and retention of talent in the biomedical workforce (see “Building Blocks").
Before joining NIH, Dr. Valantine and her colleagues at Stanford surveyed gender composition and faculty satisfaction several years after initiating a multifaceted intervention to boost recruitment and development of women faculty.4 After making a visible commitment of resources to support faculty, with special attention to women, Stanford rose from below to above national benchmarks in the representation of women among faculty. Yet significant work remains to be done, Dr. Valantine says. Her work predicts that the estimated time to achieve 50% occupancy of full professorships by women nationally approaches 50 years—“far too long using current approaches.”
In a separate review article, Dr. Valantine and co-author Christy Sandborg, MD, described the Stanford University School of Medicine Academic Biomedical Career Customization (ABCC) model, which was adapted from Deloitte’s Mass Career Customization framework and allows for development of individual career plans that span a faculty member’s total career, not just a year or two at a time. Long-term planning can enable better alignment between the work culture and values of the workforce, which will improve the outlook for women faculty, Dr. Valantine says.
The issues of work-life balance may actually be generational, Dr. Valantine explains. Veteran hospitalist Janet Nagamine, MD, BSN, SFHM, of Santa Clara, Calif., agrees.
“Nowadays, men as well as women are looking for work-life balance,” she says.
In hospital medicine, Dr. Nagamine points out, the structural changes required to effect a work-life balance for hospital leaders are often difficult to achieve.
“As productivity surveys show, HM group leaders are putting in as many RVUs as the staff,” the former SHM board member says. “There is no dedicated time for administrative duties.”
Construct a Pipeline
Barriers to advancement often are particular to characteristics of diverse populations. For example, the AAMC’s report on the U.S. physician workforce documents that in African-American physicians 40 and younger, women outnumber their male counterparts. Therefore, in the association’s Diversity in Medical Education: Facts and Figures 2012 report, the executive summary points out the need to strengthen the medical education pipeline to increase the number of African-American males who enter the premed track.
Despite the fast-growing percentage of Latino and Hispanic populations in the United States, the shortage of Latino/Hispanic physicians increased from 1980 to 2010. Latinos/Hispanics are greatly underrepresented in the medical student, resident, and faculty populations, according to John Paul Sánchez, MD, MPH, assistant dean for diversity and inclusion in the Office for Diversity and Community Engagement at Rutgers, The State University of New Jersey. Likewise, Zeppenfeldt-Cestero believes that efforts must begin much earlier with Latino and other minority and underrepresented students.
“We have to make sure our students pursue the STEM disciplines and that they also later have the education and preparation to be competitive at the MBA or MPH levels,” he says.
Dr. Sánchez, an associate professor of emergency medicine and a diversity activist since his med school days, is the recipient of last year’s Association of Hispanic Healthcare Executives’ academic leader of the year award. Since September 2014, he has been involved with Building the Next Generation of Academic Physicians Inc., which collaborates with more than 40 medical schools across the country. The initiative offers conferences designed to develop diverse medical students’ and residents’ interest in pursuing academic medicine. Open to all medical students and residents, the conference curriculum is tailored for women, UREMs, and trainees who identify as lesbian, gay, bisexual, or transgender (LGBT), he says. Seven conferences were held in 2015, 10 are planned for this year, and seven for 2017.
Healthcare Leadership Gaps
Despite their omnipresence in healthcare, there is a dearth of women in chief executive and governance roles, as has been noted by both the American College of Healthcare Executives and the National Center for Healthcare Leadership. As with academic leadership positions, the leadership gap in the administrative sector does not seem to be due to a lack of women entering graduate programs in health administration. On the contrary, since the mid-1980s women have comprised 50% to 60% of graduate students.
“This is absolutely not a pipeline issue,” says Christy Harris Lemak, PhD, FACHE, professor and chair of the Department of Health Services Administration at the University of Alabama at Birmingham School of Health Professions and lead investigator of the National Center for Healthcare Leadership’s study of women in healthcare executive positions. Other factors come into play.
In the study, she and her co-authors queried female healthcare CEOs to ascertain the critical career inflection points that led to their success.6 Those who were strategic about their careers, sought out mentors, and voiced their intentions about pursuing leadership positions were more likely to be successful in those efforts. However, individual career efforts must be coupled with overall organizational commitment to fostering inclusion (see “Path to the Top: Strategic Advice for Women").
Hospitals and healthcare organizations must pursue the development of human capital (and the diversity of their leaders) in a systematic way. “We recommended [in the study] that organizations set expectations that leaders who mentor other potential leaders be rewarded in the same way as those who hit financial targets or readmission rate targets,” Dr. Lemak says.
Leadership matters, agrees Deborah J. Bowen, FACHE, CAE, president and CEO of Chicago-based American College of Healthcare Executives.
“I think we’re getting a little smarter. Organizational leaders and trustees have a better understanding that talent development is one of the most important jobs,” she says. “If you don’t have the right people in the right places making good decisions on behalf of the patients and the populations in the communities they’re serving, the rest falls apart.”
Nuances of Mentoring
Many conversations about encouraging diversity in healthcare leadership converge around the role of effective mentoring and sponsorship. A substantial body of research supports the impact of mentoring on retention, research productivity, career satisfaction, and career development for women. It’s important to ensure that the institutional culture is geared toward mentoring junior faculty, says Jessie Kimbrough Marshall, MD, MPH, assistant professor in the Division of General Medicine Hospitalist Program at the University of Michigan Health System in Ann Arbor (UMHS).
Several of our sources pointed out that leaders must learn how to be effective mentors. More attention is being given to enhancing leaders’ mentorship skills. One example is at the Institute for Diversity in Health Management, which conducts an intensive 12-month certificate in diversity management program for practitioners. León says the program fosters ongoing networking and support through the American Leadership Council on Diversity in Healthcare by building leadership competencies.
Dr. Valantine points out that mentoring is hardly a one-style-fits-all proposition but that it is a crucial element to creating and retaining diversity. She says it should be viewed “much more broadly than it is today, and it should focus beyond the trainer-trainee relationship.”
The process is a two-way street. Denege Ward, MD, hospitalist, assistant professor of internal medicine, and director of the medical short stay unit at UMHS, says minorities need to be ready to take a leap of faith.
“Underrepresented faculty and staff should take the risk of possible failure in challenging situations but learn from it and do better and not succumb to fear in face of challenges,” Dr. Ward says.
Although mentoring is one important component in building diversity in academic medicine, Dr. Sánchez asserts that role models, champions, and sponsors are equally important.
“In addition and separate from role models, there must be in place policies and procedures that promote a climate for diverse individuals to succeed,” he says. “What’s needed is an institutional vision and strategic plan that recognizes the importance of diversity. [It] has to become a core principle.”
Dr. Marshall echoes that refrain, noting the recruitment and retention of a diverse set of leaders will take time and intentionality. She is actively engaged in organizing annual meeting mentoring panels at the Society of General Internal Medicine.
“There are still quite a few barriers for women and minorities to advance into hospital leadership roles,” she says. “We still have a long way to go. However, I’m seeing more women and people of color get into these positions. The numbers are increasing, and that encourages me.” TH
Gretchen Henkel is a freelance writer in California.
References
- Institute for Diversity in Health Management. The state of health care diversity and disparities: a benchmarking study of U.S. hospitals. Available at: http://www.diversityconnection.org/diversityconnection/leadership-conferences/Benchmarking-Survey.jsp?fll=S11.
- Top issues confronting hospitals in 2015. American College of Healthcare Executives website. Available at: https://www.ache.org/pubs/research/ceoissues.cfm. Accessed March 5, 2016.
- Association of American Medical Colleges. Diversity in the physician workforce: facts & figures 2014. Available at: http://aamcdiversityfactsandfigures.org/.
- Valantine HA, Grewal D, Ku MC, et al. The gender gap in academic medicine: comparing results from a multifaceted intervention for Stanford faculty to peer and national cohorts. Acad Med. 2014;89(6):904-911.
- Valantine H, Sandborg CI. Changing the culture of academic medicine to eliminate the gender leadership gap: 50/50 by 2020. Acad Med. 2013;88(10):1411-1413.
- Sexton DW, Lemak CH, Wainio JA. Career inflection points of women who successfully achieved the hospital CEO position. J Healthc Manag. 2014;59(5):367-383.
Path to the Top: Strategic Advice for Women
One of the cornerstones of career advancement in healthcare is to stay connected by networking and attending meetings. For women and minorities, the path to leadership may not fit into the traditional linear model of the career ladder.
“For many leadership roles, you have to be visual and present; you have to attend meetings and functions,” says Denege Ward, MD, hospitalist, assistant professor of internal medicine, and director of the medical short stay unit at the University of Michigan Health System in Ann Arbor. “For women, this is difficult. We are still in charge of families and home.”
For some women, it may be more productive to employ the notion of the “leadership labyrinth.” Others refer to a “career lattice” or employ Deloitte’s Mass Career Customization framework.
“For women, the trajectory may include working part-time while their children are small or finding local training opportunities,” says Christy Harris Lemak, PhD, FACHE, professor and chair of the Department of Health Services Administration at the University of Alabama at Birmingham School of Health Professions and lead investigator of the National Center for Healthcare Leadership’s study of women in healthcare executive positions.
Hospitalist Flora Kisuule, MD, assistant professor of medicine at Johns Hopkins School of Medicine and associate division director of the Collaborative Inpatient Medicine Service (CIMS) at Johns Hopkins Bayview Medical Center in Baltimore, is a wife and mother of a 4-year-old. She agrees the leadership path for moms can take unexpected detours. She’s been able to complete some of her administrative tasks at home through the support of her medical director. If pursuing an MBA is too daunting, she encourages her hospitalist peers to take advantage of short courses and programs in leadership.
“As women, we like to do for others,” notes Elizabeth Gundersen, MD, FHM, assistant professor of clinical biomedical sciences at the Charles E. Schmidt College of Medicine at Florida Atlantic University in Boca Raton. While at the University of Massachusetts, she was one of eight physician quality officers and associate division chief of hospital medicine. To counter the impulse to say yes to everything, including roles that distract from ultimate career goals, one of the women leaders at UMass encouraged her mentees to “think of your ideal position—and then when a position is offered, assess that against your criteria.”
Jessie Kimbrough Marshall, MD, MPH, assistant professor in the Division of General Medicine Hospitalist Program at the University of Michigan Health System, seconds that opinion.
“Try to avoid professional commitments and activities that are not aligned to your career trajectory,” Dr. Marshall advises. “You can also identify someone who is in a position that is close to what you envision for yourself and reach out to that person.”
—Gretchen Henkel
Building Blocks: NIH’s Commitment to Enhance Diversity
The National Institutes of Health (NIH) has been committed to enhancing diversity for decades, according to cardiologist Hannah A. Valantine, MD.
“NIH has made considerable investments in programming,” says Dr. Valantine. However, despite these investments, “the change has not been as rapid or sustainable as we would like it to be.”
As a first step, in October 2014, NIH announced a new set of initiatives designed to enhance the ways in which participants are engaged and trained. Three components comprise the Enhancing Diversity in the NIH-Funded Workforce program. The Building Infrastructure Leading to Diversity (BUILD) program was awarded to 10 universities that met eligibility criteria for being under-resourced. The National Research Mentoring Network (NRMN) will recruit mentors and use methods (such as “train the trainer”) to bring a more deliberate and intentional approach to cultivating mentors. The third component, the Coordinating and Evaluation Center (CEC), focuses on evaluation and dissemination of identified best practices and competencies.
“We are moving away from the assumption that just because you are a leader in your research field that that means you are a good mentor,” Dr. Valantine says.
