Carol Berczuk

How can a family physician with a demanding clinical schedule juggle patient care with the grueling administrative and travel duties required of the president-elect of the American Academy of Family Physicians (AAFP)? Lori Heim, MD, FAAFP, found the perfect compromise: Give up the family practice and become a hospitalist.

She did so last November, soon after AAFP members voted her the next president of one of the nation’s largest medical organizations. In fact, she is the only hospitalist at 104-bed Scotland Memorial Hospital in Laurinburg, N.C.

“I was looking for an opportunity while I was working as president-elect and then president of the academy,” says Dr. Heim, who takes over as president of the 94,000-member AAFP in October. “Because of the heavy travel demands, it was not possible to keep my old practice.”

Although the career swap is borne of professional necessity, Dr. Heim says her transition to HM practice has been relatively easy. “I love it. [The new job] utilizes my prior training and skills,” she says. “In private practice, I was doing rounds on my own patients, then I would have to run to the office to see my other patients. I could see the advantages of using the hospitalist services. … Now, here I am on this side.”

An active AAFP member for nearly 25 years, Dr. Heim brings a unique confluence of medical training and experience to her new role. She has firsthand knowledge of the key issues intersecting primary care and hospital-based practice—care coordination, physician reimbursement, and quality improvement. She also acknowledges that walls need to be broken down when it comes to family physicians (FP) transitioning to HM careers. More complete training and improvement in hospital administrations’ understanding of an FP’s clinical capabilities will advance their entrance into hospitalist careers.

“I think it could become a large trend because of the financial constraints on family care,” Dr. Heim says, also noting the lifestyle benefits of an HM career. “FPs often cannot do both inpatient and outpatient care. Your productivity, if you are in the clinic, must make a tradeoff between rounds and office hours—and how late at night do I want to be doing rounds?”

Bumpy Road to HM

The transition from family practice to HM is working out well for Heim, but it wasn’t as smooth as one might expect for a decorated career physician.

The daughter of a military pilot, Dr. Heim earned her bachelor’s degree with honors from Portland State University and her medical degree at the Uniformed Services University of Health Sciences in Bethesda, Md. Following her residency at Andrews Air Force Base in Maryland and a fellowship in faculty development and research at the University of North Carolina at Chapel Hill, her military medical career resembled a spiral staircase. She went from staff physician to clinic chief to residency director to chief of medical staff, with a few stops in between. After 25 years of military service, she retired as an Air Force colonel and opened a private practice.

Even with decades of training and patient care under her belt, Dr. Heim wasn’t rubber-stamped into a hospitalist position. It’s an issue she hopes to address as part of her AAFP tenure. “I know of hospitals where family physicians can admit and treat their patients but not be considered for a hospitalist position. It happened to me,” she explains. “I went and found a hospital that would use my skills.”

Hospitalist Robert Harrington, MD, FHM, knows the feeling. He had a more traditional primary-care practice before entering a HM career, and he understands the intense financial and workload pressures of family practice. Now the vice president of medical affairs for Alpharetta, Ga.-based IN Compass Health Inc. and chair of SHM’s Family Medicine Task Force, he says “there are barriers to hiring because of the wide variability in family physician training.” The root of the problem is that residents in some programs get less hospital time and experience with HM-patient encounters. “In opposed programs, they compete with other specialties and get less time,” Dr. Harrington says. “In unopposed programs, they tend to get more hospital experience and more rotations in inpatient services. Those folks can transition with little to no difficulty to hospital medicine.”

SHM President Scott Flanders, MD, FHM, associate professor and director of the hospitalist program at the University of Michigan in Ann Arbor, sees great value in what FPs can bring to HM. He wants HM to be open to those interested in a career change; however, he agrees physician training and experience can be an obstacle in the recruitment process. “The training in internal medicine is more geared to hospital medicine than it is in family practice [training],” Dr. Flanders says. “FPs must make sure they have hospital training, including the ICU. Many FP programs may not have this.” He also says FPs looking at an HM career—and internists as well—need to be “up to speed” in systems-based practice.

Any doctor, it doesn’t matter who you are, has a role to play in quality improvement.

—Lori Heim, MD, FAAFP, Scotland Memorial Hospital, Laurinburg, N.C., AAFP president-elect

Although they represent a small part of SHM’s membership, Dr. Harrington and his task force want FPs to have “representation and a voice” in the society. “They are a small but growing minority,” he says. “Four or five percent of hospitalists are family-medicine-trained by our membership rolls, but we believe it is a bigger number, as some may not be members of SHM. … We run into more problems with hospital administrators. Some of them insist on IM-trained physicians, and there just aren’t enough IMs out there.”

It’s a C-suite roadblock Dr. Heim is familiar with. “Sometimes there is a parochial view in using internists above family physicians. Why should family doctors be second? It’s a misunderstanding of the experience and what family physicians bring to the table,” she says. “They haven’t done it, so people don’t think they can. Some hospitals are underutilizing family physicians in a hospitalist role. If a physician has hospital privileges, there is no reason they should not be considered to be hired as a hospitalist.”

Tenure of Change

As AAFP president, Dr. Heim says she’ll work to improve working conditions for FPs and fight for her constituents’ rights as Washington debates national healthcare reform. The AAFP and SHM share a number of policy interests, including reimbursement reform, new technologies, and patient-safety initiatives.

“I would like to do more with the various societies to increase opportunities for family medicine,” Dr. Heim says. “In some ways, primary care is being squeezed all around. How are you going to increase the numbers of FPs when they earn less? You are not going to unless you reform the system.”

Another top priority is advancing the idea of a national network of electronic health records (EHRs). Dr. Heim says a linked EHR system would improve communication and handoffs, and help physicians limit medical errors. “That’s the key,” she says. “Until then, it is going to be a hodgepodge of solutions. As long as it requires multiple steps, there will always be slipups.

“When I was in the military, records were kept electronically, and I learned the value of having continuity of electronic records.”

Dr. Heim says she would like to partner with hospital-based physicians on QI projects. “Any doctor, it doesn’t matter who you are, has a role to play in quality improvement, either in procedures to improve outcomes in the operating room or ICU or ED. We all have a role in that,” she says. “That is one of the reasons we have supported comparative effectiveness research. Guidelines are valuable.”

As AAFP president, Dr. Heim says she won’t forget her family physician roots. Her platform is ambitious: Reform both the practice and the payment of healthcare in this country. “I think the country recognizes that the current way of paying for healthcare—built on volume and procedures rather than patient outcome—has resulted in a fragmented and disjointed process,” she says. “It’s not an even a system. … We have to look at patient experience and outcome, not ‘what procedure did we do to that patient?’

“Right now, we are paying more for lower-quality healthcare, and we are not getting the bang for our bucks. We cannot afford to continue to spend money and not get value; we really have to change this time.” TH

Carol Berczuk is a freelance writer based in New York City.

How can a family physician with a demanding clinical schedule juggle patient care with the grueling administrative and travel duties required of the president-elect of the American Academy of Family Physicians (AAFP)? Lori Heim, MD, FAAFP, found the perfect compromise: Give up the family practice and become a hospitalist.

She did so last November, soon after AAFP members voted her the next president of one of the nation’s largest medical organizations. In fact, she is the only hospitalist at 104-bed Scotland Memorial Hospital in Laurinburg, N.C.

“I was looking for an opportunity while I was working as president-elect and then president of the academy,” says Dr. Heim, who takes over as president of the 94,000-member AAFP in October. “Because of the heavy travel demands, it was not possible to keep my old practice.”

Although the career swap is borne of professional necessity, Dr. Heim says her transition to HM practice has been relatively easy. “I love it. [The new job] utilizes my prior training and skills,” she says. “In private practice, I was doing rounds on my own patients, then I would have to run to the office to see my other patients. I could see the advantages of using the hospitalist services. … Now, here I am on this side.”

An active AAFP member for nearly 25 years, Dr. Heim brings a unique confluence of medical training and experience to her new role. She has firsthand knowledge of the key issues intersecting primary care and hospital-based practice—care coordination, physician reimbursement, and quality improvement. She also acknowledges that walls need to be broken down when it comes to family physicians (FP) transitioning to HM careers. More complete training and improvement in hospital administrations’ understanding of an FP’s clinical capabilities will advance their entrance into hospitalist careers.

“I think it could become a large trend because of the financial constraints on family care,” Dr. Heim says, also noting the lifestyle benefits of an HM career. “FPs often cannot do both inpatient and outpatient care. Your productivity, if you are in the clinic, must make a tradeoff between rounds and office hours—and how late at night do I want to be doing rounds?”

Bumpy Road to HM

The transition from family practice to HM is working out well for Heim, but it wasn’t as smooth as one might expect for a decorated career physician.

The daughter of a military pilot, Dr. Heim earned her bachelor’s degree with honors from Portland State University and her medical degree at the Uniformed Services University of Health Sciences in Bethesda, Md. Following her residency at Andrews Air Force Base in Maryland and a fellowship in faculty development and research at the University of North Carolina at Chapel Hill, her military medical career resembled a spiral staircase. She went from staff physician to clinic chief to residency director to chief of medical staff, with a few stops in between. After 25 years of military service, she retired as an Air Force colonel and opened a private practice.

Even with decades of training and patient care under her belt, Dr. Heim wasn’t rubber-stamped into a hospitalist position. It’s an issue she hopes to address as part of her AAFP tenure. “I know of hospitals where family physicians can admit and treat their patients but not be considered for a hospitalist position. It happened to me,” she explains. “I went and found a hospital that would use my skills.”

Hospitalist Robert Harrington, MD, FHM, knows the feeling. He had a more traditional primary-care practice before entering a HM career, and he understands the intense financial and workload pressures of family practice. Now the vice president of medical affairs for Alpharetta, Ga.-based IN Compass Health Inc. and chair of SHM’s Family Medicine Task Force, he says “there are barriers to hiring because of the wide variability in family physician training.” The root of the problem is that residents in some programs get less hospital time and experience with HM-patient encounters. “In opposed programs, they compete with other specialties and get less time,” Dr. Harrington says. “In unopposed programs, they tend to get more hospital experience and more rotations in inpatient services. Those folks can transition with little to no difficulty to hospital medicine.”

SHM President Scott Flanders, MD, FHM, associate professor and director of the hospitalist program at the University of Michigan in Ann Arbor, sees great value in what FPs can bring to HM. He wants HM to be open to those interested in a career change; however, he agrees physician training and experience can be an obstacle in the recruitment process. “The training in internal medicine is more geared to hospital medicine than it is in family practice [training],” Dr. Flanders says. “FPs must make sure they have hospital training, including the ICU. Many FP programs may not have this.” He also says FPs looking at an HM career—and internists as well—need to be “up to speed” in systems-based practice.

Any doctor, it doesn’t matter who you are, has a role to play in quality improvement.

—Lori Heim, MD, FAAFP, Scotland Memorial Hospital, Laurinburg, N.C., AAFP president-elect

Although they represent a small part of SHM’s membership, Dr. Harrington and his task force want FPs to have “representation and a voice” in the society. “They are a small but growing minority,” he says. “Four or five percent of hospitalists are family-medicine-trained by our membership rolls, but we believe it is a bigger number, as some may not be members of SHM. … We run into more problems with hospital administrators. Some of them insist on IM-trained physicians, and there just aren’t enough IMs out there.”

It’s a C-suite roadblock Dr. Heim is familiar with. “Sometimes there is a parochial view in using internists above family physicians. Why should family doctors be second? It’s a misunderstanding of the experience and what family physicians bring to the table,” she says. “They haven’t done it, so people don’t think they can. Some hospitals are underutilizing family physicians in a hospitalist role. If a physician has hospital privileges, there is no reason they should not be considered to be hired as a hospitalist.”

Tenure of Change

As AAFP president, Dr. Heim says she’ll work to improve working conditions for FPs and fight for her constituents’ rights as Washington debates national healthcare reform. The AAFP and SHM share a number of policy interests, including reimbursement reform, new technologies, and patient-safety initiatives.

“I would like to do more with the various societies to increase opportunities for family medicine,” Dr. Heim says. “In some ways, primary care is being squeezed all around. How are you going to increase the numbers of FPs when they earn less? You are not going to unless you reform the system.”

Another top priority is advancing the idea of a national network of electronic health records (EHRs). Dr. Heim says a linked EHR system would improve communication and handoffs, and help physicians limit medical errors. “That’s the key,” she says. “Until then, it is going to be a hodgepodge of solutions. As long as it requires multiple steps, there will always be slipups.

“When I was in the military, records were kept electronically, and I learned the value of having continuity of electronic records.”

Dr. Heim says she would like to partner with hospital-based physicians on QI projects. “Any doctor, it doesn’t matter who you are, has a role to play in quality improvement, either in procedures to improve outcomes in the operating room or ICU or ED. We all have a role in that,” she says. “That is one of the reasons we have supported comparative effectiveness research. Guidelines are valuable.”

As AAFP president, Dr. Heim says she won’t forget her family physician roots. Her platform is ambitious: Reform both the practice and the payment of healthcare in this country. “I think the country recognizes that the current way of paying for healthcare—built on volume and procedures rather than patient outcome—has resulted in a fragmented and disjointed process,” she says. “It’s not an even a system. … We have to look at patient experience and outcome, not ‘what procedure did we do to that patient?’

“Right now, we are paying more for lower-quality healthcare, and we are not getting the bang for our bucks. We cannot afford to continue to spend money and not get value; we really have to change this time.” TH

Carol Berczuk is a freelance writer based in New York City.

How can a family physician with a demanding clinical schedule juggle patient care with the grueling administrative and travel duties required of the president-elect of the American Academy of Family Physicians (AAFP)? Lori Heim, MD, FAAFP, found the perfect compromise: Give up the family practice and become a hospitalist.

She did so last November, soon after AAFP members voted her the next president of one of the nation’s largest medical organizations. In fact, she is the only hospitalist at 104-bed Scotland Memorial Hospital in Laurinburg, N.C.

“I was looking for an opportunity while I was working as president-elect and then president of the academy,” says Dr. Heim, who takes over as president of the 94,000-member AAFP in October. “Because of the heavy travel demands, it was not possible to keep my old practice.”

Although the career swap is borne of professional necessity, Dr. Heim says her transition to HM practice has been relatively easy. “I love it. [The new job] utilizes my prior training and skills,” she says. “In private practice, I was doing rounds on my own patients, then I would have to run to the office to see my other patients. I could see the advantages of using the hospitalist services. … Now, here I am on this side.”

An active AAFP member for nearly 25 years, Dr. Heim brings a unique confluence of medical training and experience to her new role. She has firsthand knowledge of the key issues intersecting primary care and hospital-based practice—care coordination, physician reimbursement, and quality improvement. She also acknowledges that walls need to be broken down when it comes to family physicians (FP) transitioning to HM careers. More complete training and improvement in hospital administrations’ understanding of an FP’s clinical capabilities will advance their entrance into hospitalist careers.

“I think it could become a large trend because of the financial constraints on family care,” Dr. Heim says, also noting the lifestyle benefits of an HM career. “FPs often cannot do both inpatient and outpatient care. Your productivity, if you are in the clinic, must make a tradeoff between rounds and office hours—and how late at night do I want to be doing rounds?”

Bumpy Road to HM

The transition from family practice to HM is working out well for Heim, but it wasn’t as smooth as one might expect for a decorated career physician.

The daughter of a military pilot, Dr. Heim earned her bachelor’s degree with honors from Portland State University and her medical degree at the Uniformed Services University of Health Sciences in Bethesda, Md. Following her residency at Andrews Air Force Base in Maryland and a fellowship in faculty development and research at the University of North Carolina at Chapel Hill, her military medical career resembled a spiral staircase. She went from staff physician to clinic chief to residency director to chief of medical staff, with a few stops in between. After 25 years of military service, she retired as an Air Force colonel and opened a private practice.

Even with decades of training and patient care under her belt, Dr. Heim wasn’t rubber-stamped into a hospitalist position. It’s an issue she hopes to address as part of her AAFP tenure. “I know of hospitals where family physicians can admit and treat their patients but not be considered for a hospitalist position. It happened to me,” she explains. “I went and found a hospital that would use my skills.”

Hospitalist Robert Harrington, MD, FHM, knows the feeling. He had a more traditional primary-care practice before entering a HM career, and he understands the intense financial and workload pressures of family practice. Now the vice president of medical affairs for Alpharetta, Ga.-based IN Compass Health Inc. and chair of SHM’s Family Medicine Task Force, he says “there are barriers to hiring because of the wide variability in family physician training.” The root of the problem is that residents in some programs get less hospital time and experience with HM-patient encounters. “In opposed programs, they compete with other specialties and get less time,” Dr. Harrington says. “In unopposed programs, they tend to get more hospital experience and more rotations in inpatient services. Those folks can transition with little to no difficulty to hospital medicine.”

SHM President Scott Flanders, MD, FHM, associate professor and director of the hospitalist program at the University of Michigan in Ann Arbor, sees great value in what FPs can bring to HM. He wants HM to be open to those interested in a career change; however, he agrees physician training and experience can be an obstacle in the recruitment process. “The training in internal medicine is more geared to hospital medicine than it is in family practice [training],” Dr. Flanders says. “FPs must make sure they have hospital training, including the ICU. Many FP programs may not have this.” He also says FPs looking at an HM career—and internists as well—need to be “up to speed” in systems-based practice.

Any doctor, it doesn’t matter who you are, has a role to play in quality improvement.

—Lori Heim, MD, FAAFP, Scotland Memorial Hospital, Laurinburg, N.C., AAFP president-elect

Although they represent a small part of SHM’s membership, Dr. Harrington and his task force want FPs to have “representation and a voice” in the society. “They are a small but growing minority,” he says. “Four or five percent of hospitalists are family-medicine-trained by our membership rolls, but we believe it is a bigger number, as some may not be members of SHM. … We run into more problems with hospital administrators. Some of them insist on IM-trained physicians, and there just aren’t enough IMs out there.”

It’s a C-suite roadblock Dr. Heim is familiar with. “Sometimes there is a parochial view in using internists above family physicians. Why should family doctors be second? It’s a misunderstanding of the experience and what family physicians bring to the table,” she says. “They haven’t done it, so people don’t think they can. Some hospitals are underutilizing family physicians in a hospitalist role. If a physician has hospital privileges, there is no reason they should not be considered to be hired as a hospitalist.”

Tenure of Change

As AAFP president, Dr. Heim says she’ll work to improve working conditions for FPs and fight for her constituents’ rights as Washington debates national healthcare reform. The AAFP and SHM share a number of policy interests, including reimbursement reform, new technologies, and patient-safety initiatives.

“I would like to do more with the various societies to increase opportunities for family medicine,” Dr. Heim says. “In some ways, primary care is being squeezed all around. How are you going to increase the numbers of FPs when they earn less? You are not going to unless you reform the system.”

Another top priority is advancing the idea of a national network of electronic health records (EHRs). Dr. Heim says a linked EHR system would improve communication and handoffs, and help physicians limit medical errors. “That’s the key,” she says. “Until then, it is going to be a hodgepodge of solutions. As long as it requires multiple steps, there will always be slipups.

“When I was in the military, records were kept electronically, and I learned the value of having continuity of electronic records.”

Dr. Heim says she would like to partner with hospital-based physicians on QI projects. “Any doctor, it doesn’t matter who you are, has a role to play in quality improvement, either in procedures to improve outcomes in the operating room or ICU or ED. We all have a role in that,” she says. “That is one of the reasons we have supported comparative effectiveness research. Guidelines are valuable.”

As AAFP president, Dr. Heim says she won’t forget her family physician roots. Her platform is ambitious: Reform both the practice and the payment of healthcare in this country. “I think the country recognizes that the current way of paying for healthcare—built on volume and procedures rather than patient outcome—has resulted in a fragmented and disjointed process,” she says. “It’s not an even a system. … We have to look at patient experience and outcome, not ‘what procedure did we do to that patient?’

“Right now, we are paying more for lower-quality healthcare, and we are not getting the bang for our bucks. We cannot afford to continue to spend money and not get value; we really have to change this time.” TH

Carol Berczuk is a freelance writer based in New York City.

It has been a good year for Eric Howell, MD, FHM. Not only is he the 2009 recipient of SHM’s Award for Excellence in Teaching, but he also is the society’s newest board member.

Dr. Howell, who studied engineering before becoming a hospitalist, is director of the hospitalist division at Johns Hopkins Bayview Medical Center in Baltimore. An SHM member since 2000, he mentors 120 medical students as an assistant professor at the Johns Hopkins School of Medicine.

Dr. Howell, who is chair of SHM’s Leadership Committee and a member of the Public Policy Committee, was added to the 12-seat board this spring. Dr. Howell recently spoke to TH eWire about his award and his new position.

Question: What do you hope to accomplish during your SHM board tenure?

Answer:I am passionate about hospital medicine and enjoy advocating for hospitalists. I thought being a board member would be a mix of these two passions. My goal is to help hospitalists improve the care of their patients.

Q: How did you develop this passion for HM?

A: I love fixing broken things—improving on the hospital processes. I am an electrical engineer, and there is no specialty more based on systems improvement than hospital medicine. When I started, hospitalists were the red-headed stepchildren. Now they are implementers of quality improvement. I love patients, but I really love looking at systems and improving them.

Q: What do you see as the future of HM?

A: I hope it becomes a national leader for patients in hospital and quality improvement. I hope we set the stage nationally for changes in healthcare, such as [President] Obama is proposing. Hospitalists as individuals have been instrumental in advocating for patients. I’d like to see hospital medicine become the doctor-patient advocate.

It has been a good year for Eric Howell, MD, FHM. Not only is he the 2009 recipient of SHM’s Award for Excellence in Teaching, but he also is the society’s newest board member.

Dr. Howell, who studied engineering before becoming a hospitalist, is director of the hospitalist division at Johns Hopkins Bayview Medical Center in Baltimore. An SHM member since 2000, he mentors 120 medical students as an assistant professor at the Johns Hopkins School of Medicine.

Dr. Howell, who is chair of SHM’s Leadership Committee and a member of the Public Policy Committee, was added to the 12-seat board this spring. Dr. Howell recently spoke to TH eWire about his award and his new position.

Question: What do you hope to accomplish during your SHM board tenure?

Answer:I am passionate about hospital medicine and enjoy advocating for hospitalists. I thought being a board member would be a mix of these two passions. My goal is to help hospitalists improve the care of their patients.

Q: How did you develop this passion for HM?

A: I love fixing broken things—improving on the hospital processes. I am an electrical engineer, and there is no specialty more based on systems improvement than hospital medicine. When I started, hospitalists were the red-headed stepchildren. Now they are implementers of quality improvement. I love patients, but I really love looking at systems and improving them.

Q: What do you see as the future of HM?

A: I hope it becomes a national leader for patients in hospital and quality improvement. I hope we set the stage nationally for changes in healthcare, such as [President] Obama is proposing. Hospitalists as individuals have been instrumental in advocating for patients. I’d like to see hospital medicine become the doctor-patient advocate.

It has been a good year for Eric Howell, MD, FHM. Not only is he the 2009 recipient of SHM’s Award for Excellence in Teaching, but he also is the society’s newest board member.

Dr. Howell, who studied engineering before becoming a hospitalist, is director of the hospitalist division at Johns Hopkins Bayview Medical Center in Baltimore. An SHM member since 2000, he mentors 120 medical students as an assistant professor at the Johns Hopkins School of Medicine.

Dr. Howell, who is chair of SHM’s Leadership Committee and a member of the Public Policy Committee, was added to the 12-seat board this spring. Dr. Howell recently spoke to TH eWire about his award and his new position.

Question: What do you hope to accomplish during your SHM board tenure?

Answer:I am passionate about hospital medicine and enjoy advocating for hospitalists. I thought being a board member would be a mix of these two passions. My goal is to help hospitalists improve the care of their patients.

Q: How did you develop this passion for HM?

A: I love fixing broken things—improving on the hospital processes. I am an electrical engineer, and there is no specialty more based on systems improvement than hospital medicine. When I started, hospitalists were the red-headed stepchildren. Now they are implementers of quality improvement. I love patients, but I really love looking at systems and improving them.

Q: What do you see as the future of HM?

A: I hope it becomes a national leader for patients in hospital and quality improvement. I hope we set the stage nationally for changes in healthcare, such as [President] Obama is proposing. Hospitalists as individuals have been instrumental in advocating for patients. I’d like to see hospital medicine become the doctor-patient advocate.

The day after the Tepa District Hospital in Ghana, on the west coast of Africa, received its first sonogram machine, a life was saved. The scan picked up placenta previa in a young woman who was seven months pregnant, a complication that causes hundreds of maternal and fetal deaths each year in rural Africa.

Not this time. The ultrasound’s advance warning gave Isaac Boetang, MD, chief medical officer at Tepa District Hospital, the ability to plan ahead. Instead of facing a life-threatening hemorrhage at birth, which likely would tax his hospital’s limited resources, Dr. Boetang had time to prepare for a C-section and deliver a healthy baby to a healthy mother. In the seven months since the donated instrument arrived, Dr. Boetang estimates at least 30 more babies and mothers have been saved. Tepa’s sonogram machine was supplied by Doc to Dock, a non-profit organization working on a simple premise: Collect unused, surplus supplies from U.S. hospitals for distribution to needy hospitals in emerging countries.

Doc to Dock was born as the result of a call to charitable arms sounded by former President Bill Clinton in 2005 at his first summit meeting for the Clinton Global Initiative. He told the gathering his new foundation’s goal was “to help turn good intentions into good action and results.” Among the elite crowd of CEOs and celebrities in attendance that day was an unassuming New York cardiologist, Bruce Charash, MD, a clinical associate professor at New York University and former chief of cardiac care at Lenox Hospital in New York City. “It’s possible that year I was the only person who wasn’t a celebrity,” Dr. Charash says with a humble laugh. “They were asking us to do something to make an impact on the world, but until then my only developing world experience was spring break in 1975.”

As the former president challenged his guests to change the world, an idea Dr. Charash had long been mulling over crystallized. “I took it seriously and created a new charity,” he explains. “Send medical supplies to Africa.” When he was asked about a name, he thought slowly—and out loud. Doc, of course, his profession, to Dock, he says, as the image of a ship at a foreign port popped into his head. And that is how Dr. Charash made his own personal commitment to the Clinton Global Initiative. Doc to Dock was incorporated as a 501(c)(3) non-profit organization in February 2006. “We were the first charity formed under their umbrella,” he says. “and though we have no affiliation with them, they are an amazing support group.”

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Good Deeds

The Greek poet Homer noted some 3,000 years ago, “the charity that is a trifle to us can be precious to others.” Dr. Charash knew American hospitals, doctors’ offices, pharmacies, and clinics, housed tons of unused medical supplies. In fact, the United Way estimates more than 7,000 tons of unused medical supplies and outdated equipment are discarded every day, either incinerated or carted off to landfills. At the same time in developing countries, thousands of patients are turned away from hospitals and medical centers due to a lack of medical supplies and equipment. Doc to Dock’s mission is to correct this imbalance.

Dr. Charash began conceiving a plan to somehow turn America’s trash—precious medical resources—into treasure, channeling the leftover sutures, scalpel blades, IV tubing, bandages, outdated equipment and machinery, old hospital beds and wheelchairs to hospitals in Africa.

Then Dr. Charash stumbled across a program, aptly named Merci, at The University of Virginia Medical Center, which collects its surplus supplies and used equipment for distribution to non-profit organizations, such as the Red Cross and Project Smile. The hospital invited Dr. Charash to take a look, and he was impressed by what he saw. Since its inception in 1992, Merci has collected more than 400 tons of medical materials worth more than $80 million.

click for large version

Dr. Charash then set about soliciting donations from hospitals in his own backyard, New York City. It was a tall order. He and his small staff (one doctor, five staffers) needed to gather the surplus supplies and equipment, find a place to store it, recruit volunteers to inventory the items, and then enlist trucking and shipping companies to move the donations overseas. To find his supplies, he turned to hospitals, corporations, pharmaceutical companies, and even medical meetings. He found government and non-governmental organization partners willing to help him identify hospitals in need of and willing to receive the supplies. And, once identified, his team of volunteers began the process of matching the need with the goods collected, utilizing an online ordering system to supply the hospitals in Africa.

The Clinton name helped the cause enormously. In March, 2006, Dr. Charash reported to the Clinton Global Initiative (CGI) “the prestige of being a CGI commitment has opened many corporate doors that I do not necessarily believe would have opened without being identified with this effort.” Those open doors, coupled with Dr. Charash’s persistence, set Doc to Dock in motion.

It is proving a worthwhile voyage. One of the first partners to jump on board was Franklin Hospital in Valley Stream, N.Y., which is a part of the 305-bed North Shore Hospital System. Mary Hynes, a perioperative nurse educator, long had been discouraged by the waste of perfectly good supplies, some never even opened or routinely discarded from operating room packs. “I embraced it the nanosecond I heard it. We’d been wanting something for so long,” Hynes says. “For years, we had been throwing out stuff. It was almost criminal.”

Super Simple System

The Doc to Dock system is simple. Bright, electric-blue recycling barrels, emblazoned with the Doc to Dock logo, are stationed in the operating room and other easily accessible areas where hospital personnel can toss surplus supplies. Wrapped, sterile items, such as latex gloves, suture packs, scalpels, and bandages, routinely are overstocked in customized sterile packs as a bit of surgical “insurance.” Anything not used is discarded, still in a sterile wrap. “If a case is cancelled or something else happens,” Hynes says, “there is a sterile field with hundreds of dollars worth of supplies, which could not be reused. Everything has to be discarded and thrown away. You can’t reprocess it because there is too much liability involved.”

When Hynes switched jobs a few months ago, she transported her enthusiasm for Doc to Dock with her to the 371-bed Southside Hospital in Bay Shore, N.Y. Aided by a documentary DVD, which she showed her new colleagues, she instituted the Doc to Dock program at her new hospital. To date, the operating room and radiology department are donating excess supplies, and Hynes is planning to talk to the delivery room nurses soon.

“The barrels get filled right up,” Hynes explains. “This one hospital fills about six bins a week. Every two weeks, I call a trucker to pick them up.” Doc to Dock has arrangements with a dozen New York-area hospitals, thus far, including partnerships with the North Shore System and the Greater New York Hospital Association.

Make a Donation

The supplies may be donated, but it takes money to truck them, warehouse them and ship them to Africa. Doc to Dock relies on funding raised from corporations and philanthropic sources, plus in-kind donations from trucking and shipping companies who often move supplies for minimal or no cost.

In addition to supplies, Dr. Charash is looking for equipment. Many hospitals and clinics replace equipment, still in perfect working order, with newer models. Anesthesia machines, cryosurgery machines, mammogram machines, and cancer screening equipment, have found their way to African hospitals.

The sonogram traveled to Tepa District Hospital by way of a 40-foot shipping container, along with other supplies and equipment once destined for a U.S. scrap heap. The district serves about 100,000 villagers, and the hospital had been saving its nickels—one at a time—to purchase its own sonogram. The fundraising drive would have taken 10 years. One can only guess how many babies would have died in the meantime.

Through 2008, Doc to Dock had shipped nine containers to Ghana, Benin, Liberia, East Africa, Ethiopia, Kenya, and Uganda. Another container went to Haiti following a devastating hurricane. Four or five additional containers are just about ready to ship, Dr. Charash says. Each container costs about $25,000 per shipment. Dr. Charash estimates each shipment delivers approximately $500,000 worth of supplies and equipment.

Dr. Charash, who maintains privileges at Lenox and Mt. Sinai Medical Center in Manhattan, dreams big. He defines success by growing Doc to Dock to 100 containers per year within five years. He also wants to increase the number of hospitals donating goods, and the number of third-world hospitals receiving the supplies. Additionally, he wants to make the charity self-sustaining, as the need is always greater than the resources available.

“It’s a moral issue,” he says. “I have an obligation not to let it go to waste.” TH

Carol Berczuk is a freelance writer in New York CIty.

The day after the Tepa District Hospital in Ghana, on the west coast of Africa, received its first sonogram machine, a life was saved. The scan picked up placenta previa in a young woman who was seven months pregnant, a complication that causes hundreds of maternal and fetal deaths each year in rural Africa.

Not this time. The ultrasound’s advance warning gave Isaac Boetang, MD, chief medical officer at Tepa District Hospital, the ability to plan ahead. Instead of facing a life-threatening hemorrhage at birth, which likely would tax his hospital’s limited resources, Dr. Boetang had time to prepare for a C-section and deliver a healthy baby to a healthy mother. In the seven months since the donated instrument arrived, Dr. Boetang estimates at least 30 more babies and mothers have been saved. Tepa’s sonogram machine was supplied by Doc to Dock, a non-profit organization working on a simple premise: Collect unused, surplus supplies from U.S. hospitals for distribution to needy hospitals in emerging countries.

Doc to Dock was born as the result of a call to charitable arms sounded by former President Bill Clinton in 2005 at his first summit meeting for the Clinton Global Initiative. He told the gathering his new foundation’s goal was “to help turn good intentions into good action and results.” Among the elite crowd of CEOs and celebrities in attendance that day was an unassuming New York cardiologist, Bruce Charash, MD, a clinical associate professor at New York University and former chief of cardiac care at Lenox Hospital in New York City. “It’s possible that year I was the only person who wasn’t a celebrity,” Dr. Charash says with a humble laugh. “They were asking us to do something to make an impact on the world, but until then my only developing world experience was spring break in 1975.”

As the former president challenged his guests to change the world, an idea Dr. Charash had long been mulling over crystallized. “I took it seriously and created a new charity,” he explains. “Send medical supplies to Africa.” When he was asked about a name, he thought slowly—and out loud. Doc, of course, his profession, to Dock, he says, as the image of a ship at a foreign port popped into his head. And that is how Dr. Charash made his own personal commitment to the Clinton Global Initiative. Doc to Dock was incorporated as a 501(c)(3) non-profit organization in February 2006. “We were the first charity formed under their umbrella,” he says. “and though we have no affiliation with them, they are an amazing support group.”

click for large version

Good Deeds

The Greek poet Homer noted some 3,000 years ago, “the charity that is a trifle to us can be precious to others.” Dr. Charash knew American hospitals, doctors’ offices, pharmacies, and clinics, housed tons of unused medical supplies. In fact, the United Way estimates more than 7,000 tons of unused medical supplies and outdated equipment are discarded every day, either incinerated or carted off to landfills. At the same time in developing countries, thousands of patients are turned away from hospitals and medical centers due to a lack of medical supplies and equipment. Doc to Dock’s mission is to correct this imbalance.

Dr. Charash began conceiving a plan to somehow turn America’s trash—precious medical resources—into treasure, channeling the leftover sutures, scalpel blades, IV tubing, bandages, outdated equipment and machinery, old hospital beds and wheelchairs to hospitals in Africa.

Then Dr. Charash stumbled across a program, aptly named Merci, at The University of Virginia Medical Center, which collects its surplus supplies and used equipment for distribution to non-profit organizations, such as the Red Cross and Project Smile. The hospital invited Dr. Charash to take a look, and he was impressed by what he saw. Since its inception in 1992, Merci has collected more than 400 tons of medical materials worth more than $80 million.

click for large version

Dr. Charash then set about soliciting donations from hospitals in his own backyard, New York City. It was a tall order. He and his small staff (one doctor, five staffers) needed to gather the surplus supplies and equipment, find a place to store it, recruit volunteers to inventory the items, and then enlist trucking and shipping companies to move the donations overseas. To find his supplies, he turned to hospitals, corporations, pharmaceutical companies, and even medical meetings. He found government and non-governmental organization partners willing to help him identify hospitals in need of and willing to receive the supplies. And, once identified, his team of volunteers began the process of matching the need with the goods collected, utilizing an online ordering system to supply the hospitals in Africa.

The Clinton name helped the cause enormously. In March, 2006, Dr. Charash reported to the Clinton Global Initiative (CGI) “the prestige of being a CGI commitment has opened many corporate doors that I do not necessarily believe would have opened without being identified with this effort.” Those open doors, coupled with Dr. Charash’s persistence, set Doc to Dock in motion.

It is proving a worthwhile voyage. One of the first partners to jump on board was Franklin Hospital in Valley Stream, N.Y., which is a part of the 305-bed North Shore Hospital System. Mary Hynes, a perioperative nurse educator, long had been discouraged by the waste of perfectly good supplies, some never even opened or routinely discarded from operating room packs. “I embraced it the nanosecond I heard it. We’d been wanting something for so long,” Hynes says. “For years, we had been throwing out stuff. It was almost criminal.”

Super Simple System

The Doc to Dock system is simple. Bright, electric-blue recycling barrels, emblazoned with the Doc to Dock logo, are stationed in the operating room and other easily accessible areas where hospital personnel can toss surplus supplies. Wrapped, sterile items, such as latex gloves, suture packs, scalpels, and bandages, routinely are overstocked in customized sterile packs as a bit of surgical “insurance.” Anything not used is discarded, still in a sterile wrap. “If a case is cancelled or something else happens,” Hynes says, “there is a sterile field with hundreds of dollars worth of supplies, which could not be reused. Everything has to be discarded and thrown away. You can’t reprocess it because there is too much liability involved.”

When Hynes switched jobs a few months ago, she transported her enthusiasm for Doc to Dock with her to the 371-bed Southside Hospital in Bay Shore, N.Y. Aided by a documentary DVD, which she showed her new colleagues, she instituted the Doc to Dock program at her new hospital. To date, the operating room and radiology department are donating excess supplies, and Hynes is planning to talk to the delivery room nurses soon.

“The barrels get filled right up,” Hynes explains. “This one hospital fills about six bins a week. Every two weeks, I call a trucker to pick them up.” Doc to Dock has arrangements with a dozen New York-area hospitals, thus far, including partnerships with the North Shore System and the Greater New York Hospital Association.

Make a Donation

The supplies may be donated, but it takes money to truck them, warehouse them and ship them to Africa. Doc to Dock relies on funding raised from corporations and philanthropic sources, plus in-kind donations from trucking and shipping companies who often move supplies for minimal or no cost.

In addition to supplies, Dr. Charash is looking for equipment. Many hospitals and clinics replace equipment, still in perfect working order, with newer models. Anesthesia machines, cryosurgery machines, mammogram machines, and cancer screening equipment, have found their way to African hospitals.

The sonogram traveled to Tepa District Hospital by way of a 40-foot shipping container, along with other supplies and equipment once destined for a U.S. scrap heap. The district serves about 100,000 villagers, and the hospital had been saving its nickels—one at a time—to purchase its own sonogram. The fundraising drive would have taken 10 years. One can only guess how many babies would have died in the meantime.

Through 2008, Doc to Dock had shipped nine containers to Ghana, Benin, Liberia, East Africa, Ethiopia, Kenya, and Uganda. Another container went to Haiti following a devastating hurricane. Four or five additional containers are just about ready to ship, Dr. Charash says. Each container costs about $25,000 per shipment. Dr. Charash estimates each shipment delivers approximately $500,000 worth of supplies and equipment.

Dr. Charash, who maintains privileges at Lenox and Mt. Sinai Medical Center in Manhattan, dreams big. He defines success by growing Doc to Dock to 100 containers per year within five years. He also wants to increase the number of hospitals donating goods, and the number of third-world hospitals receiving the supplies. Additionally, he wants to make the charity self-sustaining, as the need is always greater than the resources available.

“It’s a moral issue,” he says. “I have an obligation not to let it go to waste.” TH

Carol Berczuk is a freelance writer in New York CIty.

The day after the Tepa District Hospital in Ghana, on the west coast of Africa, received its first sonogram machine, a life was saved. The scan picked up placenta previa in a young woman who was seven months pregnant, a complication that causes hundreds of maternal and fetal deaths each year in rural Africa.

Not this time. The ultrasound’s advance warning gave Isaac Boetang, MD, chief medical officer at Tepa District Hospital, the ability to plan ahead. Instead of facing a life-threatening hemorrhage at birth, which likely would tax his hospital’s limited resources, Dr. Boetang had time to prepare for a C-section and deliver a healthy baby to a healthy mother. In the seven months since the donated instrument arrived, Dr. Boetang estimates at least 30 more babies and mothers have been saved. Tepa’s sonogram machine was supplied by Doc to Dock, a non-profit organization working on a simple premise: Collect unused, surplus supplies from U.S. hospitals for distribution to needy hospitals in emerging countries.

Doc to Dock was born as the result of a call to charitable arms sounded by former President Bill Clinton in 2005 at his first summit meeting for the Clinton Global Initiative. He told the gathering his new foundation’s goal was “to help turn good intentions into good action and results.” Among the elite crowd of CEOs and celebrities in attendance that day was an unassuming New York cardiologist, Bruce Charash, MD, a clinical associate professor at New York University and former chief of cardiac care at Lenox Hospital in New York City. “It’s possible that year I was the only person who wasn’t a celebrity,” Dr. Charash says with a humble laugh. “They were asking us to do something to make an impact on the world, but until then my only developing world experience was spring break in 1975.”

As the former president challenged his guests to change the world, an idea Dr. Charash had long been mulling over crystallized. “I took it seriously and created a new charity,” he explains. “Send medical supplies to Africa.” When he was asked about a name, he thought slowly—and out loud. Doc, of course, his profession, to Dock, he says, as the image of a ship at a foreign port popped into his head. And that is how Dr. Charash made his own personal commitment to the Clinton Global Initiative. Doc to Dock was incorporated as a 501(c)(3) non-profit organization in February 2006. “We were the first charity formed under their umbrella,” he says. “and though we have no affiliation with them, they are an amazing support group.”

click for large version

Good Deeds

The Greek poet Homer noted some 3,000 years ago, “the charity that is a trifle to us can be precious to others.” Dr. Charash knew American hospitals, doctors’ offices, pharmacies, and clinics, housed tons of unused medical supplies. In fact, the United Way estimates more than 7,000 tons of unused medical supplies and outdated equipment are discarded every day, either incinerated or carted off to landfills. At the same time in developing countries, thousands of patients are turned away from hospitals and medical centers due to a lack of medical supplies and equipment. Doc to Dock’s mission is to correct this imbalance.

Dr. Charash began conceiving a plan to somehow turn America’s trash—precious medical resources—into treasure, channeling the leftover sutures, scalpel blades, IV tubing, bandages, outdated equipment and machinery, old hospital beds and wheelchairs to hospitals in Africa.

Then Dr. Charash stumbled across a program, aptly named Merci, at The University of Virginia Medical Center, which collects its surplus supplies and used equipment for distribution to non-profit organizations, such as the Red Cross and Project Smile. The hospital invited Dr. Charash to take a look, and he was impressed by what he saw. Since its inception in 1992, Merci has collected more than 400 tons of medical materials worth more than $80 million.

click for large version

Dr. Charash then set about soliciting donations from hospitals in his own backyard, New York City. It was a tall order. He and his small staff (one doctor, five staffers) needed to gather the surplus supplies and equipment, find a place to store it, recruit volunteers to inventory the items, and then enlist trucking and shipping companies to move the donations overseas. To find his supplies, he turned to hospitals, corporations, pharmaceutical companies, and even medical meetings. He found government and non-governmental organization partners willing to help him identify hospitals in need of and willing to receive the supplies. And, once identified, his team of volunteers began the process of matching the need with the goods collected, utilizing an online ordering system to supply the hospitals in Africa.

The Clinton name helped the cause enormously. In March, 2006, Dr. Charash reported to the Clinton Global Initiative (CGI) “the prestige of being a CGI commitment has opened many corporate doors that I do not necessarily believe would have opened without being identified with this effort.” Those open doors, coupled with Dr. Charash’s persistence, set Doc to Dock in motion.

It is proving a worthwhile voyage. One of the first partners to jump on board was Franklin Hospital in Valley Stream, N.Y., which is a part of the 305-bed North Shore Hospital System. Mary Hynes, a perioperative nurse educator, long had been discouraged by the waste of perfectly good supplies, some never even opened or routinely discarded from operating room packs. “I embraced it the nanosecond I heard it. We’d been wanting something for so long,” Hynes says. “For years, we had been throwing out stuff. It was almost criminal.”

Super Simple System

The Doc to Dock system is simple. Bright, electric-blue recycling barrels, emblazoned with the Doc to Dock logo, are stationed in the operating room and other easily accessible areas where hospital personnel can toss surplus supplies. Wrapped, sterile items, such as latex gloves, suture packs, scalpels, and bandages, routinely are overstocked in customized sterile packs as a bit of surgical “insurance.” Anything not used is discarded, still in a sterile wrap. “If a case is cancelled or something else happens,” Hynes says, “there is a sterile field with hundreds of dollars worth of supplies, which could not be reused. Everything has to be discarded and thrown away. You can’t reprocess it because there is too much liability involved.”

When Hynes switched jobs a few months ago, she transported her enthusiasm for Doc to Dock with her to the 371-bed Southside Hospital in Bay Shore, N.Y. Aided by a documentary DVD, which she showed her new colleagues, she instituted the Doc to Dock program at her new hospital. To date, the operating room and radiology department are donating excess supplies, and Hynes is planning to talk to the delivery room nurses soon.

“The barrels get filled right up,” Hynes explains. “This one hospital fills about six bins a week. Every two weeks, I call a trucker to pick them up.” Doc to Dock has arrangements with a dozen New York-area hospitals, thus far, including partnerships with the North Shore System and the Greater New York Hospital Association.

Make a Donation

The supplies may be donated, but it takes money to truck them, warehouse them and ship them to Africa. Doc to Dock relies on funding raised from corporations and philanthropic sources, plus in-kind donations from trucking and shipping companies who often move supplies for minimal or no cost.

In addition to supplies, Dr. Charash is looking for equipment. Many hospitals and clinics replace equipment, still in perfect working order, with newer models. Anesthesia machines, cryosurgery machines, mammogram machines, and cancer screening equipment, have found their way to African hospitals.

The sonogram traveled to Tepa District Hospital by way of a 40-foot shipping container, along with other supplies and equipment once destined for a U.S. scrap heap. The district serves about 100,000 villagers, and the hospital had been saving its nickels—one at a time—to purchase its own sonogram. The fundraising drive would have taken 10 years. One can only guess how many babies would have died in the meantime.

Through 2008, Doc to Dock had shipped nine containers to Ghana, Benin, Liberia, East Africa, Ethiopia, Kenya, and Uganda. Another container went to Haiti following a devastating hurricane. Four or five additional containers are just about ready to ship, Dr. Charash says. Each container costs about $25,000 per shipment. Dr. Charash estimates each shipment delivers approximately $500,000 worth of supplies and equipment.

Dr. Charash, who maintains privileges at Lenox and Mt. Sinai Medical Center in Manhattan, dreams big. He defines success by growing Doc to Dock to 100 containers per year within five years. He also wants to increase the number of hospitals donating goods, and the number of third-world hospitals receiving the supplies. Additionally, he wants to make the charity self-sustaining, as the need is always greater than the resources available.

“It’s a moral issue,” he says. “I have an obligation not to let it go to waste.” TH

Carol Berczuk is a freelance writer in New York CIty.

The young specialty of hospital medicine has an even younger sibling—pediatric hospital medicine. “Just seven years ago, when I put on my pediatric hospitalist badge, people would ask me, ‘What is that?’” Douglas Carlson, MD, an associate professor at the Washington University School of Medicine in St. Louis, says. “They don’t do that anymore.”

Times certainly are a changing.

With an estimated 1,500 practitioners, pediatric hospitalists make up about 9% of the total hospitalist workforce in the United States. Growth in the pediatric field has been fueled by the need for expertise in treating hospitalized pediatric patients, the increasing complexity of hospitalized cases, mandates to reduce hospital costs and readmission rates, and the curtailment of resident hours.

“The biggest thing is the whole field is blossoming,” says SHM treasurer Jack Percelay, MD.

What Lies Ahead?

Pediatric hospital medicine may be young in years, but the primary focus is on the future. Such was the theme of the Pediatric Hospital Medicine Conference held by SHM, the American Academy of Pediatrics and the Academic Pediatrics Association in July in Denver.

“We are responsible for the future of hospital medicine,” keynote speaker Sanford Melzer, MD, of the University of Washington and Children’s Memorial Hospital and Regional Medical Center of Seattle says in an interview with The Hospitalist. “So what should that future look like?”

Pediatric hospitalists are in an ideal position to improve care, Dr. Melzer said. He outlined six crucial areas for action:

• Set standards of evidence-based patient care in areas not historically addressed, such as feeding tubes and severe reflux;
• Implement safety standards for issues such as medical errors, blood infections and hand-offs to other providers;
• Develop leaders who will work to bring about these changes;
• Stabilize the workforce by better defining pediatric hospital medicine as a career path;
• Create value for hospitals;
• Promote a holistic view of hospital care as a small part of the continuum of care for chronically ill children.

As Dr. Melzer succinctly puts it, “I am here to improve the whole system, not just to give kids meds and get them out.”

“I think our evolution in hospital medicine will follow that of ER physicians very closely,” says Dr. Carlson, who started out as an ER doctor. “Within 30 years, with fellowships and training, their specialty evolved.”

A similar progression is occurring with pediatric hospitalists. Carlson said he remembers when hospitalists would complain that their colleagues in other subspecialties would “treat them like glorified residents.” Not anymore. “We are now seen as equals,” he said.

Pediatric hospitalists bring a lot to the table, Dr. Carlson said, such as broad experience in treating acutely or chronically ill hospitalized children; the ability to coordinate care; knowledge in negotiating hospital routines and protocols; and the capacity to manage family fears.

But to survive and prosper, pediatric hospitalists must create value for their institutions, Dr. Melzer said. And value is exactly what evidence-based medicine can generate, he added. Establishing evidence-based guidelines for the treatment of the 10 most common conditions affecting 80% of patients would be a huge step forward in improving patient care, Melzer explained. It would create value for patients and, ultimately, the hospital.

Lending an Ear

Communication is another key, and can be particularly important in caring for children with life-threatening or terminal illnesses, said another speaker, Margaret Hood, MD, of Orlando Healthcare and Palliative Healthcare. Listening to patients and their families is a critical part of end-of-life care.

“The palliative care offered by pediatric hospitalists becomes a lifeline to patients and their families,” she explained. “Sensitive communications can foster hope, even when the news is bad.”

Dr. Hood told the poignant story of a baby born with a lethal heart problem. “I asked her parents, “What do you want?” she said. “They told me, ‘We want her heart to get better.’”

The doctor—and the family—knew that the baby would never get better. “What else would you like?” she asked. “To hold my little girl,” the mother answered. “I have only held her twice in two months.”

“We can do that.” Dr. Hood quickly replied.

Hope comes in many forms—this time in a mother’s arms, as she finally held her daughter before she died.

Frank Talk on Stress and Career Satisfaction

The 24/7 connection hospitalists have with their institutions is the basis for much of their expertise. Then again, that same 24/7 connection can be a source of extraordinary stress.

“It is variable work, with highs and lows in volume and in unscheduled care,” Dr. Carlson explained. “For hospitalized patients, we always need call coverage. That means odd hours—or being on-call in odd hours. It means night work or evening work. Stress carries risks of unplanned turnover, absenteeism, judgment and action errors, conflicts with colleagues, physical illness and mental fatigue.

“Hospitalists may be burning out even quicker than those in other specialties,” Dr. Carlson added. “Hospitalists love clinical care, they love what they do, but they are working in an environment where they must do more and more. We have to learn how to balance enthusiasm for taking care of patients with the demands of the job.”

One area of concern among hospitals and their pediatric hospitalists is workforce stability. Young women make up the majority of the workforce, and hospitals are “dealing continuously with women who are having families,” Dr. Melzer said.

“I have some people using it as a stepping stone to other specialties,” Dr. Carlson said. “They work as pediatric hospitalists while children are young, for flexibility.”

Both Carlson and Melzer believe a sharper definition of the pediatric hospital medicine career track would make a difference. “How do we get others in the hospital to make this job satisfactory?” Dr. Carlson asked. “Hospitalists enjoy the work, but want to balance it … and make a career out of this.”

Recognition from other medical colleagues is critical to job satisfaction. More and more, pediatric hospitalists are playing key leadership roles. “We are increasingly seen as the experts for hospitalized patients,” Dr. Carlson said. “I believe we can do things better than many specialists and many generalists, because we know how hospitals work—and we are there all the time.”

What’s Next?

Implementing plans for the future of pediatric hospital medicine will require collaboration among the many specialists and groups involved in the care of children. Dr. Melzer suggests convening a “leadership summit” for representatives from all of these associations.

Dr. Percelay agreed.

“It’s exciting,” he says. “The fact that the president of the American Board of Pediatrics came and spoke to our community, along with the presidents of SHM, the American Academy of Pediatrics, and the Academic Pediatric Association, is testimony to the role we are playing in the care of hospitalized children in the United States. We need to take a lot of care to make sure we maintain links between pediatric hospitalists and primary care pediatricians.”

That would be in the best interests of all children. TH

Carol Berczuk’s is a medical journalist based in New York.

The young specialty of hospital medicine has an even younger sibling—pediatric hospital medicine. “Just seven years ago, when I put on my pediatric hospitalist badge, people would ask me, ‘What is that?’” Douglas Carlson, MD, an associate professor at the Washington University School of Medicine in St. Louis, says. “They don’t do that anymore.”

Times certainly are a changing.

With an estimated 1,500 practitioners, pediatric hospitalists make up about 9% of the total hospitalist workforce in the United States. Growth in the pediatric field has been fueled by the need for expertise in treating hospitalized pediatric patients, the increasing complexity of hospitalized cases, mandates to reduce hospital costs and readmission rates, and the curtailment of resident hours.

“The biggest thing is the whole field is blossoming,” says SHM treasurer Jack Percelay, MD.

What Lies Ahead?

Pediatric hospital medicine may be young in years, but the primary focus is on the future. Such was the theme of the Pediatric Hospital Medicine Conference held by SHM, the American Academy of Pediatrics and the Academic Pediatrics Association in July in Denver.

“We are responsible for the future of hospital medicine,” keynote speaker Sanford Melzer, MD, of the University of Washington and Children’s Memorial Hospital and Regional Medical Center of Seattle says in an interview with The Hospitalist. “So what should that future look like?”

Pediatric hospitalists are in an ideal position to improve care, Dr. Melzer said. He outlined six crucial areas for action:

• Set standards of evidence-based patient care in areas not historically addressed, such as feeding tubes and severe reflux;
• Implement safety standards for issues such as medical errors, blood infections and hand-offs to other providers;
• Develop leaders who will work to bring about these changes;
• Stabilize the workforce by better defining pediatric hospital medicine as a career path;
• Create value for hospitals;
• Promote a holistic view of hospital care as a small part of the continuum of care for chronically ill children.

As Dr. Melzer succinctly puts it, “I am here to improve the whole system, not just to give kids meds and get them out.”

“I think our evolution in hospital medicine will follow that of ER physicians very closely,” says Dr. Carlson, who started out as an ER doctor. “Within 30 years, with fellowships and training, their specialty evolved.”

A similar progression is occurring with pediatric hospitalists. Carlson said he remembers when hospitalists would complain that their colleagues in other subspecialties would “treat them like glorified residents.” Not anymore. “We are now seen as equals,” he said.

Pediatric hospitalists bring a lot to the table, Dr. Carlson said, such as broad experience in treating acutely or chronically ill hospitalized children; the ability to coordinate care; knowledge in negotiating hospital routines and protocols; and the capacity to manage family fears.

But to survive and prosper, pediatric hospitalists must create value for their institutions, Dr. Melzer said. And value is exactly what evidence-based medicine can generate, he added. Establishing evidence-based guidelines for the treatment of the 10 most common conditions affecting 80% of patients would be a huge step forward in improving patient care, Melzer explained. It would create value for patients and, ultimately, the hospital.

Lending an Ear

Communication is another key, and can be particularly important in caring for children with life-threatening or terminal illnesses, said another speaker, Margaret Hood, MD, of Orlando Healthcare and Palliative Healthcare. Listening to patients and their families is a critical part of end-of-life care.

“The palliative care offered by pediatric hospitalists becomes a lifeline to patients and their families,” she explained. “Sensitive communications can foster hope, even when the news is bad.”

Dr. Hood told the poignant story of a baby born with a lethal heart problem. “I asked her parents, “What do you want?” she said. “They told me, ‘We want her heart to get better.’”

The doctor—and the family—knew that the baby would never get better. “What else would you like?” she asked. “To hold my little girl,” the mother answered. “I have only held her twice in two months.”

“We can do that.” Dr. Hood quickly replied.

Hope comes in many forms—this time in a mother’s arms, as she finally held her daughter before she died.

Frank Talk on Stress and Career Satisfaction

The 24/7 connection hospitalists have with their institutions is the basis for much of their expertise. Then again, that same 24/7 connection can be a source of extraordinary stress.

“It is variable work, with highs and lows in volume and in unscheduled care,” Dr. Carlson explained. “For hospitalized patients, we always need call coverage. That means odd hours—or being on-call in odd hours. It means night work or evening work. Stress carries risks of unplanned turnover, absenteeism, judgment and action errors, conflicts with colleagues, physical illness and mental fatigue.

“Hospitalists may be burning out even quicker than those in other specialties,” Dr. Carlson added. “Hospitalists love clinical care, they love what they do, but they are working in an environment where they must do more and more. We have to learn how to balance enthusiasm for taking care of patients with the demands of the job.”

One area of concern among hospitals and their pediatric hospitalists is workforce stability. Young women make up the majority of the workforce, and hospitals are “dealing continuously with women who are having families,” Dr. Melzer said.

“I have some people using it as a stepping stone to other specialties,” Dr. Carlson said. “They work as pediatric hospitalists while children are young, for flexibility.”

Both Carlson and Melzer believe a sharper definition of the pediatric hospital medicine career track would make a difference. “How do we get others in the hospital to make this job satisfactory?” Dr. Carlson asked. “Hospitalists enjoy the work, but want to balance it … and make a career out of this.”

Recognition from other medical colleagues is critical to job satisfaction. More and more, pediatric hospitalists are playing key leadership roles. “We are increasingly seen as the experts for hospitalized patients,” Dr. Carlson said. “I believe we can do things better than many specialists and many generalists, because we know how hospitals work—and we are there all the time.”

What’s Next?

Implementing plans for the future of pediatric hospital medicine will require collaboration among the many specialists and groups involved in the care of children. Dr. Melzer suggests convening a “leadership summit” for representatives from all of these associations.

Dr. Percelay agreed.

“It’s exciting,” he says. “The fact that the president of the American Board of Pediatrics came and spoke to our community, along with the presidents of SHM, the American Academy of Pediatrics, and the Academic Pediatric Association, is testimony to the role we are playing in the care of hospitalized children in the United States. We need to take a lot of care to make sure we maintain links between pediatric hospitalists and primary care pediatricians.”

That would be in the best interests of all children. TH

Carol Berczuk’s is a medical journalist based in New York.

The young specialty of hospital medicine has an even younger sibling—pediatric hospital medicine. “Just seven years ago, when I put on my pediatric hospitalist badge, people would ask me, ‘What is that?’” Douglas Carlson, MD, an associate professor at the Washington University School of Medicine in St. Louis, says. “They don’t do that anymore.”

Times certainly are a changing.

With an estimated 1,500 practitioners, pediatric hospitalists make up about 9% of the total hospitalist workforce in the United States. Growth in the pediatric field has been fueled by the need for expertise in treating hospitalized pediatric patients, the increasing complexity of hospitalized cases, mandates to reduce hospital costs and readmission rates, and the curtailment of resident hours.

“The biggest thing is the whole field is blossoming,” says SHM treasurer Jack Percelay, MD.

What Lies Ahead?

Pediatric hospital medicine may be young in years, but the primary focus is on the future. Such was the theme of the Pediatric Hospital Medicine Conference held by SHM, the American Academy of Pediatrics and the Academic Pediatrics Association in July in Denver.

“We are responsible for the future of hospital medicine,” keynote speaker Sanford Melzer, MD, of the University of Washington and Children’s Memorial Hospital and Regional Medical Center of Seattle says in an interview with The Hospitalist. “So what should that future look like?”

Pediatric hospitalists are in an ideal position to improve care, Dr. Melzer said. He outlined six crucial areas for action:

• Set standards of evidence-based patient care in areas not historically addressed, such as feeding tubes and severe reflux;
• Implement safety standards for issues such as medical errors, blood infections and hand-offs to other providers;
• Develop leaders who will work to bring about these changes;
• Stabilize the workforce by better defining pediatric hospital medicine as a career path;
• Create value for hospitals;
• Promote a holistic view of hospital care as a small part of the continuum of care for chronically ill children.

As Dr. Melzer succinctly puts it, “I am here to improve the whole system, not just to give kids meds and get them out.”

“I think our evolution in hospital medicine will follow that of ER physicians very closely,” says Dr. Carlson, who started out as an ER doctor. “Within 30 years, with fellowships and training, their specialty evolved.”

A similar progression is occurring with pediatric hospitalists. Carlson said he remembers when hospitalists would complain that their colleagues in other subspecialties would “treat them like glorified residents.” Not anymore. “We are now seen as equals,” he said.

Pediatric hospitalists bring a lot to the table, Dr. Carlson said, such as broad experience in treating acutely or chronically ill hospitalized children; the ability to coordinate care; knowledge in negotiating hospital routines and protocols; and the capacity to manage family fears.

But to survive and prosper, pediatric hospitalists must create value for their institutions, Dr. Melzer said. And value is exactly what evidence-based medicine can generate, he added. Establishing evidence-based guidelines for the treatment of the 10 most common conditions affecting 80% of patients would be a huge step forward in improving patient care, Melzer explained. It would create value for patients and, ultimately, the hospital.

Lending an Ear

Communication is another key, and can be particularly important in caring for children with life-threatening or terminal illnesses, said another speaker, Margaret Hood, MD, of Orlando Healthcare and Palliative Healthcare. Listening to patients and their families is a critical part of end-of-life care.

“The palliative care offered by pediatric hospitalists becomes a lifeline to patients and their families,” she explained. “Sensitive communications can foster hope, even when the news is bad.”

Dr. Hood told the poignant story of a baby born with a lethal heart problem. “I asked her parents, “What do you want?” she said. “They told me, ‘We want her heart to get better.’”

The doctor—and the family—knew that the baby would never get better. “What else would you like?” she asked. “To hold my little girl,” the mother answered. “I have only held her twice in two months.”

“We can do that.” Dr. Hood quickly replied.

Hope comes in many forms—this time in a mother’s arms, as she finally held her daughter before she died.

Frank Talk on Stress and Career Satisfaction

The 24/7 connection hospitalists have with their institutions is the basis for much of their expertise. Then again, that same 24/7 connection can be a source of extraordinary stress.

“It is variable work, with highs and lows in volume and in unscheduled care,” Dr. Carlson explained. “For hospitalized patients, we always need call coverage. That means odd hours—or being on-call in odd hours. It means night work or evening work. Stress carries risks of unplanned turnover, absenteeism, judgment and action errors, conflicts with colleagues, physical illness and mental fatigue.

“Hospitalists may be burning out even quicker than those in other specialties,” Dr. Carlson added. “Hospitalists love clinical care, they love what they do, but they are working in an environment where they must do more and more. We have to learn how to balance enthusiasm for taking care of patients with the demands of the job.”

One area of concern among hospitals and their pediatric hospitalists is workforce stability. Young women make up the majority of the workforce, and hospitals are “dealing continuously with women who are having families,” Dr. Melzer said.

“I have some people using it as a stepping stone to other specialties,” Dr. Carlson said. “They work as pediatric hospitalists while children are young, for flexibility.”

Both Carlson and Melzer believe a sharper definition of the pediatric hospital medicine career track would make a difference. “How do we get others in the hospital to make this job satisfactory?” Dr. Carlson asked. “Hospitalists enjoy the work, but want to balance it … and make a career out of this.”

Recognition from other medical colleagues is critical to job satisfaction. More and more, pediatric hospitalists are playing key leadership roles. “We are increasingly seen as the experts for hospitalized patients,” Dr. Carlson said. “I believe we can do things better than many specialists and many generalists, because we know how hospitals work—and we are there all the time.”

What’s Next?

Implementing plans for the future of pediatric hospital medicine will require collaboration among the many specialists and groups involved in the care of children. Dr. Melzer suggests convening a “leadership summit” for representatives from all of these associations.

Dr. Percelay agreed.

“It’s exciting,” he says. “The fact that the president of the American Board of Pediatrics came and spoke to our community, along with the presidents of SHM, the American Academy of Pediatrics, and the Academic Pediatric Association, is testimony to the role we are playing in the care of hospitalized children in the United States. We need to take a lot of care to make sure we maintain links between pediatric hospitalists and primary care pediatricians.”

That would be in the best interests of all children. TH

Carol Berczuk’s is a medical journalist based in New York.

It used to be so simple. The relationship between doctors and hospitals was a straightforward quid pro quo.

Hospitals granted privileges to physicians to admit and treat their patients, and the physicians returned the favor by assuming unpaid responsibilities like taking call, providing care to uninsured or emergency patients, and serving on administrative committees.

The hospital was like a friendly club whose members exchanged benefits for duties—a win-win situation. No more.

“You used to be part of a fraternity,” explains Win Whitcomb, MD, director of performance improvement at Mercy Medical Center in Springfield, Mass., and a co-founder of SHM. “There were social rewards. There was opportunity for collegial interchange.”

Economic pressure has taken that all away. “The pace of care has greatly intensified, and the financial reward system has deteriorated significantly,” Dr. Whitcomb continues. “We treat larger numbers of uninsured patients with chronic unmanaged illnesses that require intervention. The reward system for physicians to take call and fulfill their obligation to the hospital no longer matches the responsibility.”

To illustrate the change, Dr. Whitcomb offers an example: “We have some days of the month where the call roster for general surgeries has vacancies. A month ago we had to send a patient to another hospital for an appendectomy.”

It is not an isolated instance. “Every hospital is struggling with the fact that many physicians don’t view unassigned call as a part of membership on the staff; they want to be paid for it,” says SHM President Patrick Cawley, MD, executive medical director of the Medical University of South Carolina (MUSC). And extra “pay” for services that used to be rendered gratis is one thing today’s strapped hospitals can little afford.

Committee staffing is another area undergoing change. Attending physicians are simply declining the duty. Neal Axon, MD, a hospitalist and assistant professor of medicine and pediatrics at MUSC, has seen the transformation firsthand. At one hospital his service covered, he saw the following: “At the first staff meeting there were 50 people; there was food, liquor. It was social and attendance was mandatory. You had to make three or four meetings a year to be on medical staff at this hospital.” But then, he says, attendance waned, and in the last year “dropped off precipitously.”

The old ways don’t work so what will replace them? “The point is that both physicians and hospitals need to put something on the table to collaborate,” Dr. Cawley says. “Many are saying that the hospital-physician relationship needs to change, but everyone is still feeling their way through it. What does it mean?”

SHM’s CEO Larry Wellikson, MD, sees a layered structure ahead. “Clearly the system is evolving into three kinds of physicians who use the hospital,” he says. “We are not advocating for it—just saying what it is. This is what is evolving, and hospital staffs need to see this is coming.” His three kinds of physicians are categorized by their relationship to the hospital.

The home team: “The first group is those physicians who work only at the hospital,” he says. “Their professional life is with the hospital as an institution: hospitalists, ER doctors, critical care physicians, and sometimes the anesthesiologists and radiologists. The hospital is the location of their work and provides the tools to do their job. If the hospital works well, they can do their job well. If hospital is dysfunctional, they can’t work well.”

He describes their relationship to the hospital with an anecdote: “When I was regular physician who came to the hospital just to see my patient, if they couldn’t find the chart I would scream and yell about that one patient.” Every physician faced with a missing chart thinks of it as an individual problem. “But now as a hospitalist, I try to fix the system, because all my patients are affected,” he says. “Hospitalists are on the inside trying to make it work.”

Important visitors: The second group, whom Dr. Wellikson calls important visitors, has a totally different relationship with the hospital. These are the cardiologists, orthopedic surgeons, and other medical specialties. “They are very important,” he says. “But they use the hospital intermittently and are not as tightly connected to it.”

Even so, they desire a high-quality hospital for their patients and will be willing to help set performance standards to achieve it. But their interest may not extend to patients who are not their own. “If the hospital says you have to also take care of free patients, they may choose not to,” Dr. Wellikson notes. “In fact, sometimes they have their own outpatient centers,” making them direct competitors as their competing practices sap revenue from money-making patients and procedures—all the while sending the sickest and costliest patients to the hospital.

Office-based physicians: The last of Dr. Wellikson’s groups is office-based physicians. These are the doctors who once made daily morning and evening rounds of their hospitalized patients but are now infrequently found at the bedside. “They are the physicians who don’t come to the hospital anymore: primary care physicians, endocrinologists, rheumatologists, neurologists, physicians who do all their surgery as outpatient procedures,” Dr. Wellikson explains.

This upheaval is due to tectonic shifts in both medical economics and lifestyle preferences. “Because the reimbursement for care has gone down, physicians have to see more patients to make the same amount of money,” explains Dr. Wellikson. Turning their hospitalized patients over to hospitalists allows office-based physicians to maximize their income and optimize their time.

“It increases satisfaction, limits the hours you spend in the hospital, and puts some boundaries on your work day,” Dr. Cawley says.

“Doctors want more a predictable lifestyle,” Dr. Whitcomb says. In fact, their absence is already a fait accompli in many community hospitals.

As Dr. Axon succinctly puts it: “The primary care doc has left the building.”

Dr. Cawley believes the new system is a relief to many office-based physicians. “Some do miss going to the hospital and seeing other physicians to network with them. Some miss taking care of their acute in-care patients. But I think most are relieved to not have to go to hospital. They say, ‘No, things are better this way.’”

With so many other physicians withdrawing from hospitals to their offices and clinics, Dr. Wellikson believes hospitalists will become increasingly crucial to the institution’s operation and governance. “Now the home team is going to be more active; how you staff, how you make the hospital more efficient,” he says. “The inside physicians will be much more interactive. That’s why hospital medicine has grown so rapidly.”

The explosive expansion of hospital medicine as a specialty is a direct result of the need to increase efficiency and quality standards in this new hospital atmosphere.

In addition, good home teams create a milieu in which other physicians—the important visitors (cardiologists, surgeons, orthopedists)—will want to work. “My job (as a hospitalist) is to create an environment where you can come in and do your surgery,” Dr. Wellikson points out.

The home team offers something else too: medical expertise. Providing post-operative care is not cost-effective for many surgeons. “The surgical specialists are not paid to manage medical issues,” Dr. Cawley says. “It takes time and if somebody else can manage it, that’s great.” That somebody is often a hospitalist. “There is a quality-control aspect as well,” he adds. “With hospitalists focusing on medical issues, the result is better patient care.”

Melding these groups of physicians with disparate interests and responsibilities is the next challenge for hospital leadership. It is a challenge fraught with potential pitfalls. As Dr. Wellikson explains, “The biggest obstacle is that physicians don’t do change very well.”

Administrators will turn to their institution’s hospitalists (both hospital-employed and contracted) to effect these changes and ensure overall standards and efficiency.

“I think hospitalists are in a position to bridge the gap between administrators and medical staff,” says David Yu, MD, medical director of hospitalist services at Decatur Memorial Hospital in Illinois. “I think that’s why there will be more and more hospitalists in leadership positions. That’s why hospitalists are unique: they have their feet in both worlds.”

Dr. Wellikson believes the home team will step up to the plate and take over many of the leadership duties of the new hospital.

Kenneth Patrick, MD, the ICU director of Chestnut Hill Hospital in Philadelphia, sounds a more cautionary note. Dr. Patrick, a trained hospitalist and intensivist, believes the demise of the old “hospital privilege” model is dissolving ties between physicians and their workplace. “I think younger physicians will be much more transient and more concerned with their position, work hours, and pay,” he says.

He sees a young workforce—whether hospital or office-based—as more disengaged than physicians used to be. “They will meet hospital standards, but not be actively involved in developing them,” he believes. That will be left to a small group of hospital-based physicians “who will voluntarily come forward because it is their civic responsibility. It would be nice if more physicians would work on committees, but they look at them like jury duty and they don’t want to serve.”

Dr. Patrick

“The question everyone asks is ‘What’s in it for me?’” Dr. Yu says. He notes a common sticking point: the requirement for increased documentation, which often means more work for doctors. “I think administrators are going to be in shock if they think practitioners are going to line up and say, ‘Well that’s great for the hospital.’”

The key to cooperation, says Dr. Yu, is the linking of changes to mutual benefit and patient welfare: “The administrators have to communicate that in the long run everyone will gain and it will ultimately lead to better patient care. You have to share your vision, inspire, motivate, and develop a culture of providing quality care. It’s easier said than done, but it’s the essence of medical care.”

What about patients? How do they react when a group of strangers takes over their hospital care rather than the primary care physician they often have gotten to know and trust for years? “Wanting your doctor present is counterbalanced by not having your doctor in the house,” Dr. Axon says. “Now you can see a physician anytime during the day.” And most patients are glad for the tradeoff. Dr. Yu has found the same dynamic with his patients at Decatur Memorial Hospital. “I can just count on one hand patients who were not happy the primary care physician wasn’t there,” he says. “Patients are more concerned with having their problems solved than with who is solving them.” And he makes sure his hospitalist staff never undermines the office based physicians. “We always say we are not better physicians, we are just more available.”

While they may have left the hospital, office-based physicians still will be a large presence in it by advocating for their patients. “If my whole currency is, ‘Do I have hospital privileges?’ then all my decisions are based on that,” Dr. Wellikson says.

Armed with the power of their patient referrals, office-based physicians will be able to demand that hospitals show proof of performance—thus becoming their patients’ ombudsmen. “I’m your shopper for the best healthcare, so the hospital has to step up to the plate and make sure it gets the business,” Dr. Wellikson explains. “They want standards because their patients need the best treatment, and they will have a choice of which hospital to put their patients into. If I now have a choice of three hospitals, I am looking to see that you are the Lexus of healthcare for my patients.”

Looking out for their patients’ interests is not the only way office-based physicians will continue to affect hospitals. As in-patient revenue declines, hospitals must look to the outpatient side to make up the difference. “The hospital is lucky if they break even on the inpatient side; they get the vast majority of money on the outpatient side: testing and procedures that private attendings are sending to the hospital,” Dr. Yu says.

He cautions against alienating those private practitioners by forcing change that is not mutually beneficial. “If you alienate them, you might lose money because they can send their patients to a different institution,” he warns. “These are the same doctors that never admit patients but do order the outpatient ultrasounds, blood tests, and therapies that are all money makers for the hospital. Why would you want to alienate these physicians?”

Dr. Patrick agrees: office-based physicians and hospitalists need each other. “I have to work with the primaries,” he says. “They are my source of referrals.”

There is another group that hospitals must learn to court, according to Dr. Axon: its own hospitalists. “I think you will see more innovative solutions to problems of recruiting hospital-based physicians to perform these functions,” he says. “For that to happen, the doctors will need to get more out of it. Many hospitalist groups are in a quandary; they are expected to do all these extra things, but pay is closely liked to clinical production and the number of patients they see. Those incentives will have to be aligned.”

All of which increases the reliance on—and importance of—those physicians who do work in the hospital—the home team. As Dr. Yu puts it: “I think the hospitalist model, whether you like or hate it, is the wave of the future.” TH

Carol Berczuk is a journalist based in New York.

It used to be so simple. The relationship between doctors and hospitals was a straightforward quid pro quo.

Hospitals granted privileges to physicians to admit and treat their patients, and the physicians returned the favor by assuming unpaid responsibilities like taking call, providing care to uninsured or emergency patients, and serving on administrative committees.

The hospital was like a friendly club whose members exchanged benefits for duties—a win-win situation. No more.

“You used to be part of a fraternity,” explains Win Whitcomb, MD, director of performance improvement at Mercy Medical Center in Springfield, Mass., and a co-founder of SHM. “There were social rewards. There was opportunity for collegial interchange.”

Economic pressure has taken that all away. “The pace of care has greatly intensified, and the financial reward system has deteriorated significantly,” Dr. Whitcomb continues. “We treat larger numbers of uninsured patients with chronic unmanaged illnesses that require intervention. The reward system for physicians to take call and fulfill their obligation to the hospital no longer matches the responsibility.”

To illustrate the change, Dr. Whitcomb offers an example: “We have some days of the month where the call roster for general surgeries has vacancies. A month ago we had to send a patient to another hospital for an appendectomy.”

It is not an isolated instance. “Every hospital is struggling with the fact that many physicians don’t view unassigned call as a part of membership on the staff; they want to be paid for it,” says SHM President Patrick Cawley, MD, executive medical director of the Medical University of South Carolina (MUSC). And extra “pay” for services that used to be rendered gratis is one thing today’s strapped hospitals can little afford.

Committee staffing is another area undergoing change. Attending physicians are simply declining the duty. Neal Axon, MD, a hospitalist and assistant professor of medicine and pediatrics at MUSC, has seen the transformation firsthand. At one hospital his service covered, he saw the following: “At the first staff meeting there were 50 people; there was food, liquor. It was social and attendance was mandatory. You had to make three or four meetings a year to be on medical staff at this hospital.” But then, he says, attendance waned, and in the last year “dropped off precipitously.”

The old ways don’t work so what will replace them? “The point is that both physicians and hospitals need to put something on the table to collaborate,” Dr. Cawley says. “Many are saying that the hospital-physician relationship needs to change, but everyone is still feeling their way through it. What does it mean?”

SHM’s CEO Larry Wellikson, MD, sees a layered structure ahead. “Clearly the system is evolving into three kinds of physicians who use the hospital,” he says. “We are not advocating for it—just saying what it is. This is what is evolving, and hospital staffs need to see this is coming.” His three kinds of physicians are categorized by their relationship to the hospital.

The home team: “The first group is those physicians who work only at the hospital,” he says. “Their professional life is with the hospital as an institution: hospitalists, ER doctors, critical care physicians, and sometimes the anesthesiologists and radiologists. The hospital is the location of their work and provides the tools to do their job. If the hospital works well, they can do their job well. If hospital is dysfunctional, they can’t work well.”

He describes their relationship to the hospital with an anecdote: “When I was regular physician who came to the hospital just to see my patient, if they couldn’t find the chart I would scream and yell about that one patient.” Every physician faced with a missing chart thinks of it as an individual problem. “But now as a hospitalist, I try to fix the system, because all my patients are affected,” he says. “Hospitalists are on the inside trying to make it work.”

Important visitors: The second group, whom Dr. Wellikson calls important visitors, has a totally different relationship with the hospital. These are the cardiologists, orthopedic surgeons, and other medical specialties. “They are very important,” he says. “But they use the hospital intermittently and are not as tightly connected to it.”

Even so, they desire a high-quality hospital for their patients and will be willing to help set performance standards to achieve it. But their interest may not extend to patients who are not their own. “If the hospital says you have to also take care of free patients, they may choose not to,” Dr. Wellikson notes. “In fact, sometimes they have their own outpatient centers,” making them direct competitors as their competing practices sap revenue from money-making patients and procedures—all the while sending the sickest and costliest patients to the hospital.

Office-based physicians: The last of Dr. Wellikson’s groups is office-based physicians. These are the doctors who once made daily morning and evening rounds of their hospitalized patients but are now infrequently found at the bedside. “They are the physicians who don’t come to the hospital anymore: primary care physicians, endocrinologists, rheumatologists, neurologists, physicians who do all their surgery as outpatient procedures,” Dr. Wellikson explains.

This upheaval is due to tectonic shifts in both medical economics and lifestyle preferences. “Because the reimbursement for care has gone down, physicians have to see more patients to make the same amount of money,” explains Dr. Wellikson. Turning their hospitalized patients over to hospitalists allows office-based physicians to maximize their income and optimize their time.

“It increases satisfaction, limits the hours you spend in the hospital, and puts some boundaries on your work day,” Dr. Cawley says.

“Doctors want more a predictable lifestyle,” Dr. Whitcomb says. In fact, their absence is already a fait accompli in many community hospitals.

As Dr. Axon succinctly puts it: “The primary care doc has left the building.”

Dr. Cawley believes the new system is a relief to many office-based physicians. “Some do miss going to the hospital and seeing other physicians to network with them. Some miss taking care of their acute in-care patients. But I think most are relieved to not have to go to hospital. They say, ‘No, things are better this way.’”

With so many other physicians withdrawing from hospitals to their offices and clinics, Dr. Wellikson believes hospitalists will become increasingly crucial to the institution’s operation and governance. “Now the home team is going to be more active; how you staff, how you make the hospital more efficient,” he says. “The inside physicians will be much more interactive. That’s why hospital medicine has grown so rapidly.”

The explosive expansion of hospital medicine as a specialty is a direct result of the need to increase efficiency and quality standards in this new hospital atmosphere.

In addition, good home teams create a milieu in which other physicians—the important visitors (cardiologists, surgeons, orthopedists)—will want to work. “My job (as a hospitalist) is to create an environment where you can come in and do your surgery,” Dr. Wellikson points out.

The home team offers something else too: medical expertise. Providing post-operative care is not cost-effective for many surgeons. “The surgical specialists are not paid to manage medical issues,” Dr. Cawley says. “It takes time and if somebody else can manage it, that’s great.” That somebody is often a hospitalist. “There is a quality-control aspect as well,” he adds. “With hospitalists focusing on medical issues, the result is better patient care.”

Melding these groups of physicians with disparate interests and responsibilities is the next challenge for hospital leadership. It is a challenge fraught with potential pitfalls. As Dr. Wellikson explains, “The biggest obstacle is that physicians don’t do change very well.”

Administrators will turn to their institution’s hospitalists (both hospital-employed and contracted) to effect these changes and ensure overall standards and efficiency.

“I think hospitalists are in a position to bridge the gap between administrators and medical staff,” says David Yu, MD, medical director of hospitalist services at Decatur Memorial Hospital in Illinois. “I think that’s why there will be more and more hospitalists in leadership positions. That’s why hospitalists are unique: they have their feet in both worlds.”

Dr. Wellikson believes the home team will step up to the plate and take over many of the leadership duties of the new hospital.

Kenneth Patrick, MD, the ICU director of Chestnut Hill Hospital in Philadelphia, sounds a more cautionary note. Dr. Patrick, a trained hospitalist and intensivist, believes the demise of the old “hospital privilege” model is dissolving ties between physicians and their workplace. “I think younger physicians will be much more transient and more concerned with their position, work hours, and pay,” he says.

He sees a young workforce—whether hospital or office-based—as more disengaged than physicians used to be. “They will meet hospital standards, but not be actively involved in developing them,” he believes. That will be left to a small group of hospital-based physicians “who will voluntarily come forward because it is their civic responsibility. It would be nice if more physicians would work on committees, but they look at them like jury duty and they don’t want to serve.”

Dr. Patrick

“The question everyone asks is ‘What’s in it for me?’” Dr. Yu says. He notes a common sticking point: the requirement for increased documentation, which often means more work for doctors. “I think administrators are going to be in shock if they think practitioners are going to line up and say, ‘Well that’s great for the hospital.’”

The key to cooperation, says Dr. Yu, is the linking of changes to mutual benefit and patient welfare: “The administrators have to communicate that in the long run everyone will gain and it will ultimately lead to better patient care. You have to share your vision, inspire, motivate, and develop a culture of providing quality care. It’s easier said than done, but it’s the essence of medical care.”

What about patients? How do they react when a group of strangers takes over their hospital care rather than the primary care physician they often have gotten to know and trust for years? “Wanting your doctor present is counterbalanced by not having your doctor in the house,” Dr. Axon says. “Now you can see a physician anytime during the day.” And most patients are glad for the tradeoff. Dr. Yu has found the same dynamic with his patients at Decatur Memorial Hospital. “I can just count on one hand patients who were not happy the primary care physician wasn’t there,” he says. “Patients are more concerned with having their problems solved than with who is solving them.” And he makes sure his hospitalist staff never undermines the office based physicians. “We always say we are not better physicians, we are just more available.”

While they may have left the hospital, office-based physicians still will be a large presence in it by advocating for their patients. “If my whole currency is, ‘Do I have hospital privileges?’ then all my decisions are based on that,” Dr. Wellikson says.

Armed with the power of their patient referrals, office-based physicians will be able to demand that hospitals show proof of performance—thus becoming their patients’ ombudsmen. “I’m your shopper for the best healthcare, so the hospital has to step up to the plate and make sure it gets the business,” Dr. Wellikson explains. “They want standards because their patients need the best treatment, and they will have a choice of which hospital to put their patients into. If I now have a choice of three hospitals, I am looking to see that you are the Lexus of healthcare for my patients.”

Looking out for their patients’ interests is not the only way office-based physicians will continue to affect hospitals. As in-patient revenue declines, hospitals must look to the outpatient side to make up the difference. “The hospital is lucky if they break even on the inpatient side; they get the vast majority of money on the outpatient side: testing and procedures that private attendings are sending to the hospital,” Dr. Yu says.

He cautions against alienating those private practitioners by forcing change that is not mutually beneficial. “If you alienate them, you might lose money because they can send their patients to a different institution,” he warns. “These are the same doctors that never admit patients but do order the outpatient ultrasounds, blood tests, and therapies that are all money makers for the hospital. Why would you want to alienate these physicians?”

Dr. Patrick agrees: office-based physicians and hospitalists need each other. “I have to work with the primaries,” he says. “They are my source of referrals.”

There is another group that hospitals must learn to court, according to Dr. Axon: its own hospitalists. “I think you will see more innovative solutions to problems of recruiting hospital-based physicians to perform these functions,” he says. “For that to happen, the doctors will need to get more out of it. Many hospitalist groups are in a quandary; they are expected to do all these extra things, but pay is closely liked to clinical production and the number of patients they see. Those incentives will have to be aligned.”

All of which increases the reliance on—and importance of—those physicians who do work in the hospital—the home team. As Dr. Yu puts it: “I think the hospitalist model, whether you like or hate it, is the wave of the future.” TH

Carol Berczuk is a journalist based in New York.

It used to be so simple. The relationship between doctors and hospitals was a straightforward quid pro quo.

Hospitals granted privileges to physicians to admit and treat their patients, and the physicians returned the favor by assuming unpaid responsibilities like taking call, providing care to uninsured or emergency patients, and serving on administrative committees.

The hospital was like a friendly club whose members exchanged benefits for duties—a win-win situation. No more.

“You used to be part of a fraternity,” explains Win Whitcomb, MD, director of performance improvement at Mercy Medical Center in Springfield, Mass., and a co-founder of SHM. “There were social rewards. There was opportunity for collegial interchange.”

Economic pressure has taken that all away. “The pace of care has greatly intensified, and the financial reward system has deteriorated significantly,” Dr. Whitcomb continues. “We treat larger numbers of uninsured patients with chronic unmanaged illnesses that require intervention. The reward system for physicians to take call and fulfill their obligation to the hospital no longer matches the responsibility.”

To illustrate the change, Dr. Whitcomb offers an example: “We have some days of the month where the call roster for general surgeries has vacancies. A month ago we had to send a patient to another hospital for an appendectomy.”

It is not an isolated instance. “Every hospital is struggling with the fact that many physicians don’t view unassigned call as a part of membership on the staff; they want to be paid for it,” says SHM President Patrick Cawley, MD, executive medical director of the Medical University of South Carolina (MUSC). And extra “pay” for services that used to be rendered gratis is one thing today’s strapped hospitals can little afford.

Committee staffing is another area undergoing change. Attending physicians are simply declining the duty. Neal Axon, MD, a hospitalist and assistant professor of medicine and pediatrics at MUSC, has seen the transformation firsthand. At one hospital his service covered, he saw the following: “At the first staff meeting there were 50 people; there was food, liquor. It was social and attendance was mandatory. You had to make three or four meetings a year to be on medical staff at this hospital.” But then, he says, attendance waned, and in the last year “dropped off precipitously.”

The old ways don’t work so what will replace them? “The point is that both physicians and hospitals need to put something on the table to collaborate,” Dr. Cawley says. “Many are saying that the hospital-physician relationship needs to change, but everyone is still feeling their way through it. What does it mean?”

SHM’s CEO Larry Wellikson, MD, sees a layered structure ahead. “Clearly the system is evolving into three kinds of physicians who use the hospital,” he says. “We are not advocating for it—just saying what it is. This is what is evolving, and hospital staffs need to see this is coming.” His three kinds of physicians are categorized by their relationship to the hospital.

The home team: “The first group is those physicians who work only at the hospital,” he says. “Their professional life is with the hospital as an institution: hospitalists, ER doctors, critical care physicians, and sometimes the anesthesiologists and radiologists. The hospital is the location of their work and provides the tools to do their job. If the hospital works well, they can do their job well. If hospital is dysfunctional, they can’t work well.”

He describes their relationship to the hospital with an anecdote: “When I was regular physician who came to the hospital just to see my patient, if they couldn’t find the chart I would scream and yell about that one patient.” Every physician faced with a missing chart thinks of it as an individual problem. “But now as a hospitalist, I try to fix the system, because all my patients are affected,” he says. “Hospitalists are on the inside trying to make it work.”

Important visitors: The second group, whom Dr. Wellikson calls important visitors, has a totally different relationship with the hospital. These are the cardiologists, orthopedic surgeons, and other medical specialties. “They are very important,” he says. “But they use the hospital intermittently and are not as tightly connected to it.”

Even so, they desire a high-quality hospital for their patients and will be willing to help set performance standards to achieve it. But their interest may not extend to patients who are not their own. “If the hospital says you have to also take care of free patients, they may choose not to,” Dr. Wellikson notes. “In fact, sometimes they have their own outpatient centers,” making them direct competitors as their competing practices sap revenue from money-making patients and procedures—all the while sending the sickest and costliest patients to the hospital.

Office-based physicians: The last of Dr. Wellikson’s groups is office-based physicians. These are the doctors who once made daily morning and evening rounds of their hospitalized patients but are now infrequently found at the bedside. “They are the physicians who don’t come to the hospital anymore: primary care physicians, endocrinologists, rheumatologists, neurologists, physicians who do all their surgery as outpatient procedures,” Dr. Wellikson explains.

This upheaval is due to tectonic shifts in both medical economics and lifestyle preferences. “Because the reimbursement for care has gone down, physicians have to see more patients to make the same amount of money,” explains Dr. Wellikson. Turning their hospitalized patients over to hospitalists allows office-based physicians to maximize their income and optimize their time.

“It increases satisfaction, limits the hours you spend in the hospital, and puts some boundaries on your work day,” Dr. Cawley says.

“Doctors want more a predictable lifestyle,” Dr. Whitcomb says. In fact, their absence is already a fait accompli in many community hospitals.

As Dr. Axon succinctly puts it: “The primary care doc has left the building.”

Dr. Cawley believes the new system is a relief to many office-based physicians. “Some do miss going to the hospital and seeing other physicians to network with them. Some miss taking care of their acute in-care patients. But I think most are relieved to not have to go to hospital. They say, ‘No, things are better this way.’”

With so many other physicians withdrawing from hospitals to their offices and clinics, Dr. Wellikson believes hospitalists will become increasingly crucial to the institution’s operation and governance. “Now the home team is going to be more active; how you staff, how you make the hospital more efficient,” he says. “The inside physicians will be much more interactive. That’s why hospital medicine has grown so rapidly.”

The explosive expansion of hospital medicine as a specialty is a direct result of the need to increase efficiency and quality standards in this new hospital atmosphere.

In addition, good home teams create a milieu in which other physicians—the important visitors (cardiologists, surgeons, orthopedists)—will want to work. “My job (as a hospitalist) is to create an environment where you can come in and do your surgery,” Dr. Wellikson points out.

The home team offers something else too: medical expertise. Providing post-operative care is not cost-effective for many surgeons. “The surgical specialists are not paid to manage medical issues,” Dr. Cawley says. “It takes time and if somebody else can manage it, that’s great.” That somebody is often a hospitalist. “There is a quality-control aspect as well,” he adds. “With hospitalists focusing on medical issues, the result is better patient care.”

Melding these groups of physicians with disparate interests and responsibilities is the next challenge for hospital leadership. It is a challenge fraught with potential pitfalls. As Dr. Wellikson explains, “The biggest obstacle is that physicians don’t do change very well.”

Administrators will turn to their institution’s hospitalists (both hospital-employed and contracted) to effect these changes and ensure overall standards and efficiency.

“I think hospitalists are in a position to bridge the gap between administrators and medical staff,” says David Yu, MD, medical director of hospitalist services at Decatur Memorial Hospital in Illinois. “I think that’s why there will be more and more hospitalists in leadership positions. That’s why hospitalists are unique: they have their feet in both worlds.”

Dr. Wellikson believes the home team will step up to the plate and take over many of the leadership duties of the new hospital.

Kenneth Patrick, MD, the ICU director of Chestnut Hill Hospital in Philadelphia, sounds a more cautionary note. Dr. Patrick, a trained hospitalist and intensivist, believes the demise of the old “hospital privilege” model is dissolving ties between physicians and their workplace. “I think younger physicians will be much more transient and more concerned with their position, work hours, and pay,” he says.

He sees a young workforce—whether hospital or office-based—as more disengaged than physicians used to be. “They will meet hospital standards, but not be actively involved in developing them,” he believes. That will be left to a small group of hospital-based physicians “who will voluntarily come forward because it is their civic responsibility. It would be nice if more physicians would work on committees, but they look at them like jury duty and they don’t want to serve.”

Dr. Patrick

“The question everyone asks is ‘What’s in it for me?’” Dr. Yu says. He notes a common sticking point: the requirement for increased documentation, which often means more work for doctors. “I think administrators are going to be in shock if they think practitioners are going to line up and say, ‘Well that’s great for the hospital.’”

The key to cooperation, says Dr. Yu, is the linking of changes to mutual benefit and patient welfare: “The administrators have to communicate that in the long run everyone will gain and it will ultimately lead to better patient care. You have to share your vision, inspire, motivate, and develop a culture of providing quality care. It’s easier said than done, but it’s the essence of medical care.”

What about patients? How do they react when a group of strangers takes over their hospital care rather than the primary care physician they often have gotten to know and trust for years? “Wanting your doctor present is counterbalanced by not having your doctor in the house,” Dr. Axon says. “Now you can see a physician anytime during the day.” And most patients are glad for the tradeoff. Dr. Yu has found the same dynamic with his patients at Decatur Memorial Hospital. “I can just count on one hand patients who were not happy the primary care physician wasn’t there,” he says. “Patients are more concerned with having their problems solved than with who is solving them.” And he makes sure his hospitalist staff never undermines the office based physicians. “We always say we are not better physicians, we are just more available.”

While they may have left the hospital, office-based physicians still will be a large presence in it by advocating for their patients. “If my whole currency is, ‘Do I have hospital privileges?’ then all my decisions are based on that,” Dr. Wellikson says.

Armed with the power of their patient referrals, office-based physicians will be able to demand that hospitals show proof of performance—thus becoming their patients’ ombudsmen. “I’m your shopper for the best healthcare, so the hospital has to step up to the plate and make sure it gets the business,” Dr. Wellikson explains. “They want standards because their patients need the best treatment, and they will have a choice of which hospital to put their patients into. If I now have a choice of three hospitals, I am looking to see that you are the Lexus of healthcare for my patients.”

Looking out for their patients’ interests is not the only way office-based physicians will continue to affect hospitals. As in-patient revenue declines, hospitals must look to the outpatient side to make up the difference. “The hospital is lucky if they break even on the inpatient side; they get the vast majority of money on the outpatient side: testing and procedures that private attendings are sending to the hospital,” Dr. Yu says.

He cautions against alienating those private practitioners by forcing change that is not mutually beneficial. “If you alienate them, you might lose money because they can send their patients to a different institution,” he warns. “These are the same doctors that never admit patients but do order the outpatient ultrasounds, blood tests, and therapies that are all money makers for the hospital. Why would you want to alienate these physicians?”

Dr. Patrick agrees: office-based physicians and hospitalists need each other. “I have to work with the primaries,” he says. “They are my source of referrals.”

There is another group that hospitals must learn to court, according to Dr. Axon: its own hospitalists. “I think you will see more innovative solutions to problems of recruiting hospital-based physicians to perform these functions,” he says. “For that to happen, the doctors will need to get more out of it. Many hospitalist groups are in a quandary; they are expected to do all these extra things, but pay is closely liked to clinical production and the number of patients they see. Those incentives will have to be aligned.”

All of which increases the reliance on—and importance of—those physicians who do work in the hospital—the home team. As Dr. Yu puts it: “I think the hospitalist model, whether you like or hate it, is the wave of the future.” TH

Carol Berczuk is a journalist based in New York.

What does being lean have to do with operating a hospital? Well, when you’re talking about the lean method known as the Toyota Production System, it just may be what puts hospitals back in the driver’s seat of their bottom lines.

Six years ago, few hospital administrators had ever heard the term. Today, what began as an experiment at Seattle’s Virginia Mason Medical Center is sweeping through cash-strapped hospitals across the country.

Originally envisioned by the Japanese automaker as a way of doing more with less, the much-copied management system is becoming the gold standard for U.S. hospitals. They are betting that going Toyota lean will streamline processes, increase employee satisfaction, improve their finances, and most importantly, enhance patient care.

What does being lean entail?

“At its core, lean is a process-improvement methodology and management improvement system,” says Mark Graban, a senior consultant with Ortho-Clinical Diagnostics’ ValuMetrix Services in Rochester, N.Y. Graban teaches the Toyota system to hospitals throughout the country. One of the system’s most basic tenets is respect for the work force. Another is that it does not assign blame. Instead, Graban explains, “Lean engages the work force to improve the work they are involved in—improving process and quality, and reducing delays for patients.”

Can Hospitalists Go Lean?

Hospitals have used lean to improve productivity in areas as diverse as inventory, testing, purchasing, and food service. What about their most critical function — patient care? Can lean help hospitalists to perform their jobs, too?

“Yes,” asserts Christopher Kim, MD, MBA, of the Departments of Internal Medicine and Pediatrics at the University of Michigan. Dr. Kim studied lean and applied it at his hospital in Ann Arbor. “To really do lean projects well, you need the buy-in of the physicians—the hospitalists. I believe hospitalists have a huge role in how successful lean projects can be. It behooves them to participate in these process improvement projects and take a lead role.”

Managers must sign on, as well.

“Lean gets managers out of their offices and into various departments to see what the problems are,” says Graban, whose book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction is due out this summer. “Lean allows you to see it firsthand rather than relying on budget reports. We take executives to the nursing unit, and you see the light bulb go off. They say, ‘We need to help our employees provide care.’ ’’

Waste Not, Want Not

Lean solutions involve looking at processes, breaking them down into parts, and eliminating waste. Waste is an important concept in lean thinking, especially as it relates to time and motion.

“Lean is not necessarily about clinical care, but about reducing inefficiencies in processes needed for that care, by transforming waste into value,” explains Dr. Kim.

Waste, Graban asserts, “is any problem that pops up during the day that delays care.” Just ask a patient waiting for a doctor to write discharge orders or a nurse running around searching for missing supplies how much time is spent waiting.

“Up to 40% of time spent in hospitals is waste,” says Dr. Kim.

When lean strategy eliminates wasted time and motion that means efficiency, productivity, employee satisfaction, and patient satisfaction all increase. “That’s how hospitalists can use this—so much of what we do is about process,” Dr. Kim explains. “Once a clinical encounter is finished, much of what we do to achieve our goal of treating patients is really about those processes.” And processes are what lean seeks to optimize.

Hospitalist Brian Bossard, MD, director, Inpatient Associates, Lincoln, Neb., uses lean concepts to optimize his physicians’ patient loads. “We try to get each individual physician’s patient census close together—physically put the beds together to reduce the time the doctors are moving from one place to another,” he says. “It’s also much easier to communicate with nurses; [it’s] a significant savings in time and manpower.”

Lean Solutions

Max Langham, MD, chief of surgery at LeBonheur Children’s Medical Center in Memphis, Tenn., puts hospitals’ dilemmas about quality succinctly: “Most places want to be good and are working at getting better. It’s one thing to talk about it, but how do you do it?” His hospital chose Toyota lean, hiring Graban’s team to train the operating room (OR) staff.

Time-motion studies of the OR revealed a chaotic inventory system. Supplies were not systematically accounted for, resulting in either too much or inappropriate inventory. Sterilized surgical kits would be opened for one instrument, requiring resterilization of the rest. Establishing a master control inventory system and a master location for each supply made it easier to track them all in real time. First-year inventory savings were $243,828.

“Nurses know exactly where to go to get things now,” says Dr. Langham. “Lean’s focus was reducing waste and freeing up resources—and in a constrained environment that made a ton of sense.”

Recognizing what’s wrong with a process is the first step toward improving it, says Dr. Kim. He thinks hospitalists are uniquely qualified for the job. “They’re the ones who have the clear picture of the entire process for the patient,” he says. “They have the overview.”

One of the first processes Dr. Kim’s team examined was the turnaround time for placing PIC lines so patients could be discharged to home IV therapy. Applying lean methods reduced the average PIC wait time from 26 hours to 16, a reduction of 38%, with a concomitant savings in time, money, and patient satisfaction.

In radiation oncology, treatment for brain and bone metastases was streamlined from a three-visit procedure to a single hospital appointment by using lean methods. “The radiology workers at first did not like it,” says Dr. Kim. They feared job loss or increased workload, but soon found that lean is more about working smarter than harder. “Now they love it,” he says.

Success is not always assured. “We’ve had some areas of great success, some mediocre, and a few failures,” says Dr. Kim. The failures? “If too many departments and too many people are involved in one project, it tends to lead to failure,” he explains. “We are still on the upward phase of the learning curve.”

Lean is definitely not a set of cookie-cutter procedures. Each hospital has its own bottlenecks and waste points. Lean is a way of finding them and finding a customized correction for them.

“People used to work around obstacles,” Dr. Kim says. “Now we try to identify and eliminate them so people don’t have to work around them.”

At St. Joseph’s Mercy Hospital in Ypsilanti, Mich., inefficient ordering of diagnostic studies was a problem. “We have primarily used lean in test ordering and reporting,” says hospitalist Lakshmi Halasyamani, MD. “We decreased waiting times both for patients and for important diagnostic studies.” She thinks this can be of special value to hospitalists. “We benefit even more than others because we’re in the hospital all the time and ordering all the tests all the time,” she says.

Meanwhile, Mark Pool, MD, laboratory director of Riverside Medical Center in Kankakee, Ill., saw room for improvement in his lab. “Just walking through I saw a lot of redundant effort,” he explains. The results of his lean initiative were impressive. By getting a handle on inventory control, eliminating batching of tests, and standardizing procedures, Dr. Pool decreased test time considerably. That minimized backups in the emergency department. “Sitting in ED is like sitting in a taxi with the meter running,” he says. His department is able to turn the meter off. The lean project cost his hospital $300,000. The savings? “I don’t know, exactly,” he says. “But right off the bat with basic inventory control management, we saved $30,000 before we even blinked.” And he expects those savings to continue to add up.

Complacency is the Enemy

Any organization has its own long-term institutional culture. That culture also can lead to complacency, a “we’ve-always-done-it-this-way” attitude. That was the culture the Denver Health System wanted to change when it chose to go lean.

Eugene Chu, MD, director of the hospital medicine program at Denver Health, says his hospital’s lean program was initiated by Patricia Gabow, MD, the hospital’s CEO. “She had a vision that Denver Health and most healthcare systems were doing the same things for 20, 30, 40 years,” he says. “They had not changed anything. And she felt there was a lot to learn from outsiders, [like] how to manage operations and different products of the medical center.”

Dr. Gabow secured a grant from the Agency for Healthcare Research and Quality (AHRQ) to bring in a team of consultants to train hospital personnel as “black belts” in Toyota lean. Dr. Chu is one of them. “We have tried to improve patient flow and work flow,” he says. One project is to standardize the admissions procedure. “Before, house staff wrote things on crumpled pieces of paper and stored them in various places,” he recalls. Now, admissions are the responsibility of the hospitalists. No more chasing after a busy resident to get the pertinent facts out of his pocket. Admissions are transparent on Excel folders in hospital computers, for all staff to access.

Dr. Chu warns that Toyota lean doesn’t come easily or inexpensively. “To really do it right it is a significant investment. It is a set of tools and knowledge that you have to learn properly, and practice and develop,” he says, adding “Our black belts take 100 hours of training.”

Lean savings relating to billing procedures or food service can be easily measured. Savings related to actual patient care can be difficult to quantify. Dr. Chu says the hospital realized a $5 million net savings for all its lean projects. “It is just 1% of the operating budget, but it still helps,” he says.

Lean isn’t the only management system available. Julia Wright, MD, a hospitalist at the University of Wisconsin Hospital and Clinics in Madison, says her hospital is using a different approach to increase efficiency. “You need a system that can expedite care,” she says. “Lean is one way of doing it, but there are other models, too.”

Her hospital’s solution is a new IT system, with handheld computers into which physicians can enter and access data in real time. “Lean may not be IT-based, but it’s the same bottom line—a way of bringing care to the patient instead of bringing the patient to care,” she explains. That saves patients time. “When we look at patient satisfaction surveys, people get really frustrated with wait times. That’s what angers them,” she says.

As good as lean is, “I don’t think “lean” is [the be-all, end-all solution] to hospital efficiency and quality and safety,” Dr. Kim says. Other systems have come and gone as hospitals seek to rein in costs and improve care. “It’s not the model you choose,” Dr. Kim concludes. “It’s how you look at the model and decide to incorporate it into your hospital.” TH

Carol Berczuk is a medical journalist based in New York.

What does being lean have to do with operating a hospital? Well, when you’re talking about the lean method known as the Toyota Production System, it just may be what puts hospitals back in the driver’s seat of their bottom lines.

Six years ago, few hospital administrators had ever heard the term. Today, what began as an experiment at Seattle’s Virginia Mason Medical Center is sweeping through cash-strapped hospitals across the country.

Originally envisioned by the Japanese automaker as a way of doing more with less, the much-copied management system is becoming the gold standard for U.S. hospitals. They are betting that going Toyota lean will streamline processes, increase employee satisfaction, improve their finances, and most importantly, enhance patient care.

What does being lean entail?

“At its core, lean is a process-improvement methodology and management improvement system,” says Mark Graban, a senior consultant with Ortho-Clinical Diagnostics’ ValuMetrix Services in Rochester, N.Y. Graban teaches the Toyota system to hospitals throughout the country. One of the system’s most basic tenets is respect for the work force. Another is that it does not assign blame. Instead, Graban explains, “Lean engages the work force to improve the work they are involved in—improving process and quality, and reducing delays for patients.”

Can Hospitalists Go Lean?

Hospitals have used lean to improve productivity in areas as diverse as inventory, testing, purchasing, and food service. What about their most critical function — patient care? Can lean help hospitalists to perform their jobs, too?

“Yes,” asserts Christopher Kim, MD, MBA, of the Departments of Internal Medicine and Pediatrics at the University of Michigan. Dr. Kim studied lean and applied it at his hospital in Ann Arbor. “To really do lean projects well, you need the buy-in of the physicians—the hospitalists. I believe hospitalists have a huge role in how successful lean projects can be. It behooves them to participate in these process improvement projects and take a lead role.”

Managers must sign on, as well.

“Lean gets managers out of their offices and into various departments to see what the problems are,” says Graban, whose book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction is due out this summer. “Lean allows you to see it firsthand rather than relying on budget reports. We take executives to the nursing unit, and you see the light bulb go off. They say, ‘We need to help our employees provide care.’ ’’

Waste Not, Want Not

Lean solutions involve looking at processes, breaking them down into parts, and eliminating waste. Waste is an important concept in lean thinking, especially as it relates to time and motion.

“Lean is not necessarily about clinical care, but about reducing inefficiencies in processes needed for that care, by transforming waste into value,” explains Dr. Kim.

Waste, Graban asserts, “is any problem that pops up during the day that delays care.” Just ask a patient waiting for a doctor to write discharge orders or a nurse running around searching for missing supplies how much time is spent waiting.

“Up to 40% of time spent in hospitals is waste,” says Dr. Kim.

When lean strategy eliminates wasted time and motion that means efficiency, productivity, employee satisfaction, and patient satisfaction all increase. “That’s how hospitalists can use this—so much of what we do is about process,” Dr. Kim explains. “Once a clinical encounter is finished, much of what we do to achieve our goal of treating patients is really about those processes.” And processes are what lean seeks to optimize.

Hospitalist Brian Bossard, MD, director, Inpatient Associates, Lincoln, Neb., uses lean concepts to optimize his physicians’ patient loads. “We try to get each individual physician’s patient census close together—physically put the beds together to reduce the time the doctors are moving from one place to another,” he says. “It’s also much easier to communicate with nurses; [it’s] a significant savings in time and manpower.”

Lean Solutions

Max Langham, MD, chief of surgery at LeBonheur Children’s Medical Center in Memphis, Tenn., puts hospitals’ dilemmas about quality succinctly: “Most places want to be good and are working at getting better. It’s one thing to talk about it, but how do you do it?” His hospital chose Toyota lean, hiring Graban’s team to train the operating room (OR) staff.

Time-motion studies of the OR revealed a chaotic inventory system. Supplies were not systematically accounted for, resulting in either too much or inappropriate inventory. Sterilized surgical kits would be opened for one instrument, requiring resterilization of the rest. Establishing a master control inventory system and a master location for each supply made it easier to track them all in real time. First-year inventory savings were $243,828.

“Nurses know exactly where to go to get things now,” says Dr. Langham. “Lean’s focus was reducing waste and freeing up resources—and in a constrained environment that made a ton of sense.”

Recognizing what’s wrong with a process is the first step toward improving it, says Dr. Kim. He thinks hospitalists are uniquely qualified for the job. “They’re the ones who have the clear picture of the entire process for the patient,” he says. “They have the overview.”

One of the first processes Dr. Kim’s team examined was the turnaround time for placing PIC lines so patients could be discharged to home IV therapy. Applying lean methods reduced the average PIC wait time from 26 hours to 16, a reduction of 38%, with a concomitant savings in time, money, and patient satisfaction.

In radiation oncology, treatment for brain and bone metastases was streamlined from a three-visit procedure to a single hospital appointment by using lean methods. “The radiology workers at first did not like it,” says Dr. Kim. They feared job loss or increased workload, but soon found that lean is more about working smarter than harder. “Now they love it,” he says.

Success is not always assured. “We’ve had some areas of great success, some mediocre, and a few failures,” says Dr. Kim. The failures? “If too many departments and too many people are involved in one project, it tends to lead to failure,” he explains. “We are still on the upward phase of the learning curve.”

Lean is definitely not a set of cookie-cutter procedures. Each hospital has its own bottlenecks and waste points. Lean is a way of finding them and finding a customized correction for them.

“People used to work around obstacles,” Dr. Kim says. “Now we try to identify and eliminate them so people don’t have to work around them.”

At St. Joseph’s Mercy Hospital in Ypsilanti, Mich., inefficient ordering of diagnostic studies was a problem. “We have primarily used lean in test ordering and reporting,” says hospitalist Lakshmi Halasyamani, MD. “We decreased waiting times both for patients and for important diagnostic studies.” She thinks this can be of special value to hospitalists. “We benefit even more than others because we’re in the hospital all the time and ordering all the tests all the time,” she says.

Meanwhile, Mark Pool, MD, laboratory director of Riverside Medical Center in Kankakee, Ill., saw room for improvement in his lab. “Just walking through I saw a lot of redundant effort,” he explains. The results of his lean initiative were impressive. By getting a handle on inventory control, eliminating batching of tests, and standardizing procedures, Dr. Pool decreased test time considerably. That minimized backups in the emergency department. “Sitting in ED is like sitting in a taxi with the meter running,” he says. His department is able to turn the meter off. The lean project cost his hospital $300,000. The savings? “I don’t know, exactly,” he says. “But right off the bat with basic inventory control management, we saved $30,000 before we even blinked.” And he expects those savings to continue to add up.

Complacency is the Enemy

Any organization has its own long-term institutional culture. That culture also can lead to complacency, a “we’ve-always-done-it-this-way” attitude. That was the culture the Denver Health System wanted to change when it chose to go lean.

Eugene Chu, MD, director of the hospital medicine program at Denver Health, says his hospital’s lean program was initiated by Patricia Gabow, MD, the hospital’s CEO. “She had a vision that Denver Health and most healthcare systems were doing the same things for 20, 30, 40 years,” he says. “They had not changed anything. And she felt there was a lot to learn from outsiders, [like] how to manage operations and different products of the medical center.”

Dr. Gabow secured a grant from the Agency for Healthcare Research and Quality (AHRQ) to bring in a team of consultants to train hospital personnel as “black belts” in Toyota lean. Dr. Chu is one of them. “We have tried to improve patient flow and work flow,” he says. One project is to standardize the admissions procedure. “Before, house staff wrote things on crumpled pieces of paper and stored them in various places,” he recalls. Now, admissions are the responsibility of the hospitalists. No more chasing after a busy resident to get the pertinent facts out of his pocket. Admissions are transparent on Excel folders in hospital computers, for all staff to access.

Dr. Chu warns that Toyota lean doesn’t come easily or inexpensively. “To really do it right it is a significant investment. It is a set of tools and knowledge that you have to learn properly, and practice and develop,” he says, adding “Our black belts take 100 hours of training.”

Lean savings relating to billing procedures or food service can be easily measured. Savings related to actual patient care can be difficult to quantify. Dr. Chu says the hospital realized a $5 million net savings for all its lean projects. “It is just 1% of the operating budget, but it still helps,” he says.

Lean isn’t the only management system available. Julia Wright, MD, a hospitalist at the University of Wisconsin Hospital and Clinics in Madison, says her hospital is using a different approach to increase efficiency. “You need a system that can expedite care,” she says. “Lean is one way of doing it, but there are other models, too.”

Her hospital’s solution is a new IT system, with handheld computers into which physicians can enter and access data in real time. “Lean may not be IT-based, but it’s the same bottom line—a way of bringing care to the patient instead of bringing the patient to care,” she explains. That saves patients time. “When we look at patient satisfaction surveys, people get really frustrated with wait times. That’s what angers them,” she says.

As good as lean is, “I don’t think “lean” is [the be-all, end-all solution] to hospital efficiency and quality and safety,” Dr. Kim says. Other systems have come and gone as hospitals seek to rein in costs and improve care. “It’s not the model you choose,” Dr. Kim concludes. “It’s how you look at the model and decide to incorporate it into your hospital.” TH

Carol Berczuk is a medical journalist based in New York.

What does being lean have to do with operating a hospital? Well, when you’re talking about the lean method known as the Toyota Production System, it just may be what puts hospitals back in the driver’s seat of their bottom lines.

Six years ago, few hospital administrators had ever heard the term. Today, what began as an experiment at Seattle’s Virginia Mason Medical Center is sweeping through cash-strapped hospitals across the country.

Originally envisioned by the Japanese automaker as a way of doing more with less, the much-copied management system is becoming the gold standard for U.S. hospitals. They are betting that going Toyota lean will streamline processes, increase employee satisfaction, improve their finances, and most importantly, enhance patient care.

What does being lean entail?

“At its core, lean is a process-improvement methodology and management improvement system,” says Mark Graban, a senior consultant with Ortho-Clinical Diagnostics’ ValuMetrix Services in Rochester, N.Y. Graban teaches the Toyota system to hospitals throughout the country. One of the system’s most basic tenets is respect for the work force. Another is that it does not assign blame. Instead, Graban explains, “Lean engages the work force to improve the work they are involved in—improving process and quality, and reducing delays for patients.”

Can Hospitalists Go Lean?

Hospitals have used lean to improve productivity in areas as diverse as inventory, testing, purchasing, and food service. What about their most critical function — patient care? Can lean help hospitalists to perform their jobs, too?

“Yes,” asserts Christopher Kim, MD, MBA, of the Departments of Internal Medicine and Pediatrics at the University of Michigan. Dr. Kim studied lean and applied it at his hospital in Ann Arbor. “To really do lean projects well, you need the buy-in of the physicians—the hospitalists. I believe hospitalists have a huge role in how successful lean projects can be. It behooves them to participate in these process improvement projects and take a lead role.”

Managers must sign on, as well.

“Lean gets managers out of their offices and into various departments to see what the problems are,” says Graban, whose book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction is due out this summer. “Lean allows you to see it firsthand rather than relying on budget reports. We take executives to the nursing unit, and you see the light bulb go off. They say, ‘We need to help our employees provide care.’ ’’

Waste Not, Want Not

Lean solutions involve looking at processes, breaking them down into parts, and eliminating waste. Waste is an important concept in lean thinking, especially as it relates to time and motion.

“Lean is not necessarily about clinical care, but about reducing inefficiencies in processes needed for that care, by transforming waste into value,” explains Dr. Kim.

Waste, Graban asserts, “is any problem that pops up during the day that delays care.” Just ask a patient waiting for a doctor to write discharge orders or a nurse running around searching for missing supplies how much time is spent waiting.

“Up to 40% of time spent in hospitals is waste,” says Dr. Kim.

When lean strategy eliminates wasted time and motion that means efficiency, productivity, employee satisfaction, and patient satisfaction all increase. “That’s how hospitalists can use this—so much of what we do is about process,” Dr. Kim explains. “Once a clinical encounter is finished, much of what we do to achieve our goal of treating patients is really about those processes.” And processes are what lean seeks to optimize.

Hospitalist Brian Bossard, MD, director, Inpatient Associates, Lincoln, Neb., uses lean concepts to optimize his physicians’ patient loads. “We try to get each individual physician’s patient census close together—physically put the beds together to reduce the time the doctors are moving from one place to another,” he says. “It’s also much easier to communicate with nurses; [it’s] a significant savings in time and manpower.”

Lean Solutions

Max Langham, MD, chief of surgery at LeBonheur Children’s Medical Center in Memphis, Tenn., puts hospitals’ dilemmas about quality succinctly: “Most places want to be good and are working at getting better. It’s one thing to talk about it, but how do you do it?” His hospital chose Toyota lean, hiring Graban’s team to train the operating room (OR) staff.

Time-motion studies of the OR revealed a chaotic inventory system. Supplies were not systematically accounted for, resulting in either too much or inappropriate inventory. Sterilized surgical kits would be opened for one instrument, requiring resterilization of the rest. Establishing a master control inventory system and a master location for each supply made it easier to track them all in real time. First-year inventory savings were $243,828.

“Nurses know exactly where to go to get things now,” says Dr. Langham. “Lean’s focus was reducing waste and freeing up resources—and in a constrained environment that made a ton of sense.”

Recognizing what’s wrong with a process is the first step toward improving it, says Dr. Kim. He thinks hospitalists are uniquely qualified for the job. “They’re the ones who have the clear picture of the entire process for the patient,” he says. “They have the overview.”

One of the first processes Dr. Kim’s team examined was the turnaround time for placing PIC lines so patients could be discharged to home IV therapy. Applying lean methods reduced the average PIC wait time from 26 hours to 16, a reduction of 38%, with a concomitant savings in time, money, and patient satisfaction.

In radiation oncology, treatment for brain and bone metastases was streamlined from a three-visit procedure to a single hospital appointment by using lean methods. “The radiology workers at first did not like it,” says Dr. Kim. They feared job loss or increased workload, but soon found that lean is more about working smarter than harder. “Now they love it,” he says.

Success is not always assured. “We’ve had some areas of great success, some mediocre, and a few failures,” says Dr. Kim. The failures? “If too many departments and too many people are involved in one project, it tends to lead to failure,” he explains. “We are still on the upward phase of the learning curve.”

Lean is definitely not a set of cookie-cutter procedures. Each hospital has its own bottlenecks and waste points. Lean is a way of finding them and finding a customized correction for them.

“People used to work around obstacles,” Dr. Kim says. “Now we try to identify and eliminate them so people don’t have to work around them.”

At St. Joseph’s Mercy Hospital in Ypsilanti, Mich., inefficient ordering of diagnostic studies was a problem. “We have primarily used lean in test ordering and reporting,” says hospitalist Lakshmi Halasyamani, MD. “We decreased waiting times both for patients and for important diagnostic studies.” She thinks this can be of special value to hospitalists. “We benefit even more than others because we’re in the hospital all the time and ordering all the tests all the time,” she says.

Meanwhile, Mark Pool, MD, laboratory director of Riverside Medical Center in Kankakee, Ill., saw room for improvement in his lab. “Just walking through I saw a lot of redundant effort,” he explains. The results of his lean initiative were impressive. By getting a handle on inventory control, eliminating batching of tests, and standardizing procedures, Dr. Pool decreased test time considerably. That minimized backups in the emergency department. “Sitting in ED is like sitting in a taxi with the meter running,” he says. His department is able to turn the meter off. The lean project cost his hospital $300,000. The savings? “I don’t know, exactly,” he says. “But right off the bat with basic inventory control management, we saved $30,000 before we even blinked.” And he expects those savings to continue to add up.

Complacency is the Enemy

Any organization has its own long-term institutional culture. That culture also can lead to complacency, a “we’ve-always-done-it-this-way” attitude. That was the culture the Denver Health System wanted to change when it chose to go lean.

Eugene Chu, MD, director of the hospital medicine program at Denver Health, says his hospital’s lean program was initiated by Patricia Gabow, MD, the hospital’s CEO. “She had a vision that Denver Health and most healthcare systems were doing the same things for 20, 30, 40 years,” he says. “They had not changed anything. And she felt there was a lot to learn from outsiders, [like] how to manage operations and different products of the medical center.”

Dr. Gabow secured a grant from the Agency for Healthcare Research and Quality (AHRQ) to bring in a team of consultants to train hospital personnel as “black belts” in Toyota lean. Dr. Chu is one of them. “We have tried to improve patient flow and work flow,” he says. One project is to standardize the admissions procedure. “Before, house staff wrote things on crumpled pieces of paper and stored them in various places,” he recalls. Now, admissions are the responsibility of the hospitalists. No more chasing after a busy resident to get the pertinent facts out of his pocket. Admissions are transparent on Excel folders in hospital computers, for all staff to access.

Dr. Chu warns that Toyota lean doesn’t come easily or inexpensively. “To really do it right it is a significant investment. It is a set of tools and knowledge that you have to learn properly, and practice and develop,” he says, adding “Our black belts take 100 hours of training.”

Lean savings relating to billing procedures or food service can be easily measured. Savings related to actual patient care can be difficult to quantify. Dr. Chu says the hospital realized a $5 million net savings for all its lean projects. “It is just 1% of the operating budget, but it still helps,” he says.

Lean isn’t the only management system available. Julia Wright, MD, a hospitalist at the University of Wisconsin Hospital and Clinics in Madison, says her hospital is using a different approach to increase efficiency. “You need a system that can expedite care,” she says. “Lean is one way of doing it, but there are other models, too.”

Her hospital’s solution is a new IT system, with handheld computers into which physicians can enter and access data in real time. “Lean may not be IT-based, but it’s the same bottom line—a way of bringing care to the patient instead of bringing the patient to care,” she explains. That saves patients time. “When we look at patient satisfaction surveys, people get really frustrated with wait times. That’s what angers them,” she says.

As good as lean is, “I don’t think “lean” is [the be-all, end-all solution] to hospital efficiency and quality and safety,” Dr. Kim says. Other systems have come and gone as hospitals seek to rein in costs and improve care. “It’s not the model you choose,” Dr. Kim concludes. “It’s how you look at the model and decide to incorporate it into your hospital.” TH

Carol Berczuk is a medical journalist based in New York.