Dr.

I am leaving my current hospitalist company, and they are telling me that I have to pay them back the $10,000 sign-on/relocation bonus that was originally given to me. When I looked at the contract that I was given at the onset of our interview meetings, there was no clause stating a timeframe or any mention of me paying this back if I left the company. However, when I stated that I was giving my three-month notice, they said that their reasoning was based on a clause in the contract that says if I left before the end of the first year, then I would need to return the bonus.

I have worked for this company for nine months and moved to this city specifically for the purpose of this job. I didn’t believe what they were saying because I had read over the initial contract very well ... but then I compared that initial contract and the one that I actually signed. They changed some things that we never talked about; for instance, they changed the insurance from occurrence type to claims made, and they added a sentence at the end of the paragraph discussing the bonus.

I just think this was not very honest of them. Do I have any recourse? I wouldn’t even mind paying back a portion of it, but it makes me so mad that they obviously were being sneaky in changing the 14-page contract.

Cindy Nichols, MD

Austin, Texas

Dr. Hospitalist responds: I am sorry to hear of the troubles. When I read your note, I thought unfortunately of the English playwright Noel Coward, who once said, “It is discouraging to think how many people are shocked by honesty and how few by deceit.” Unfortunately, this happens all too commonly. Sounds like you are the unfortunate victim of nothing more than a bait-and-switch. I am not a lawyer and am not offering legal advice, but I suggest you contact a healthcare attorney familiar with employment contracts in Texas. But it would seem to me that since you did sign the contract, I suspect you have little recourse.

Although you are going to be out some money, I actually think this is more damaging to your employer than it is to you. You might have to repay the $10,000, but this could cost your employer much more. In today’s environment, in which anyone who has access to the Internet or a smartphone, one’s reputation can be reviled or revered at the whim of one’s keystroke. It does not seem to me that it makes much sense to engage in business in such a deceitful manner. Word can spread easily about a dishonest employer, even though the contract handed to you could have been the action of a single dishonest employee, rather than a corporate strategy. If the company is fortunate, you will take the time to let someone senior in the company know what happened to you. With this information, they can review their practice and assure that it doesn’t happen to another employee.

More likely, I expect that you are not likely to waste your time speaking with anyone else in the company, but that instead you will tell friends and colleagues about how you were victimized by this employer. It is a small world and this company’s image will suffer immeasurably from these water-cooler discussions. But I encourage you to take the high road: Contact a higher-up in the company and hold a professional discussion with them.

Best-case scenario: They respect your feedback and honor the original contract. Worst-case scenario: You walk away from people you really don’t want to work with, and you walk away with your dignity intact. TH

I am leaving my current hospitalist company, and they are telling me that I have to pay them back the $10,000 sign-on/relocation bonus that was originally given to me. When I looked at the contract that I was given at the onset of our interview meetings, there was no clause stating a timeframe or any mention of me paying this back if I left the company. However, when I stated that I was giving my three-month notice, they said that their reasoning was based on a clause in the contract that says if I left before the end of the first year, then I would need to return the bonus.

I have worked for this company for nine months and moved to this city specifically for the purpose of this job. I didn’t believe what they were saying because I had read over the initial contract very well ... but then I compared that initial contract and the one that I actually signed. They changed some things that we never talked about; for instance, they changed the insurance from occurrence type to claims made, and they added a sentence at the end of the paragraph discussing the bonus.

I just think this was not very honest of them. Do I have any recourse? I wouldn’t even mind paying back a portion of it, but it makes me so mad that they obviously were being sneaky in changing the 14-page contract.

Cindy Nichols, MD

Austin, Texas

Dr. Hospitalist responds: I am sorry to hear of the troubles. When I read your note, I thought unfortunately of the English playwright Noel Coward, who once said, “It is discouraging to think how many people are shocked by honesty and how few by deceit.” Unfortunately, this happens all too commonly. Sounds like you are the unfortunate victim of nothing more than a bait-and-switch. I am not a lawyer and am not offering legal advice, but I suggest you contact a healthcare attorney familiar with employment contracts in Texas. But it would seem to me that since you did sign the contract, I suspect you have little recourse.

Although you are going to be out some money, I actually think this is more damaging to your employer than it is to you. You might have to repay the $10,000, but this could cost your employer much more. In today’s environment, in which anyone who has access to the Internet or a smartphone, one’s reputation can be reviled or revered at the whim of one’s keystroke. It does not seem to me that it makes much sense to engage in business in such a deceitful manner. Word can spread easily about a dishonest employer, even though the contract handed to you could have been the action of a single dishonest employee, rather than a corporate strategy. If the company is fortunate, you will take the time to let someone senior in the company know what happened to you. With this information, they can review their practice and assure that it doesn’t happen to another employee.

More likely, I expect that you are not likely to waste your time speaking with anyone else in the company, but that instead you will tell friends and colleagues about how you were victimized by this employer. It is a small world and this company’s image will suffer immeasurably from these water-cooler discussions. But I encourage you to take the high road: Contact a higher-up in the company and hold a professional discussion with them.

Best-case scenario: They respect your feedback and honor the original contract. Worst-case scenario: You walk away from people you really don’t want to work with, and you walk away with your dignity intact. TH

I am leaving my current hospitalist company, and they are telling me that I have to pay them back the $10,000 sign-on/relocation bonus that was originally given to me. When I looked at the contract that I was given at the onset of our interview meetings, there was no clause stating a timeframe or any mention of me paying this back if I left the company. However, when I stated that I was giving my three-month notice, they said that their reasoning was based on a clause in the contract that says if I left before the end of the first year, then I would need to return the bonus.

I have worked for this company for nine months and moved to this city specifically for the purpose of this job. I didn’t believe what they were saying because I had read over the initial contract very well ... but then I compared that initial contract and the one that I actually signed. They changed some things that we never talked about; for instance, they changed the insurance from occurrence type to claims made, and they added a sentence at the end of the paragraph discussing the bonus.

I just think this was not very honest of them. Do I have any recourse? I wouldn’t even mind paying back a portion of it, but it makes me so mad that they obviously were being sneaky in changing the 14-page contract.

Cindy Nichols, MD

Austin, Texas

Dr. Hospitalist responds: I am sorry to hear of the troubles. When I read your note, I thought unfortunately of the English playwright Noel Coward, who once said, “It is discouraging to think how many people are shocked by honesty and how few by deceit.” Unfortunately, this happens all too commonly. Sounds like you are the unfortunate victim of nothing more than a bait-and-switch. I am not a lawyer and am not offering legal advice, but I suggest you contact a healthcare attorney familiar with employment contracts in Texas. But it would seem to me that since you did sign the contract, I suspect you have little recourse.

Although you are going to be out some money, I actually think this is more damaging to your employer than it is to you. You might have to repay the $10,000, but this could cost your employer much more. In today’s environment, in which anyone who has access to the Internet or a smartphone, one’s reputation can be reviled or revered at the whim of one’s keystroke. It does not seem to me that it makes much sense to engage in business in such a deceitful manner. Word can spread easily about a dishonest employer, even though the contract handed to you could have been the action of a single dishonest employee, rather than a corporate strategy. If the company is fortunate, you will take the time to let someone senior in the company know what happened to you. With this information, they can review their practice and assure that it doesn’t happen to another employee.

More likely, I expect that you are not likely to waste your time speaking with anyone else in the company, but that instead you will tell friends and colleagues about how you were victimized by this employer. It is a small world and this company’s image will suffer immeasurably from these water-cooler discussions. But I encourage you to take the high road: Contact a higher-up in the company and hold a professional discussion with them.

Best-case scenario: They respect your feedback and honor the original contract. Worst-case scenario: You walk away from people you really don’t want to work with, and you walk away with your dignity intact. TH

I have doubts: Are there any guidelines about “bouncing” patients between teaching and nonteaching services in a teaching hospital?

Srikanth Seethala, MD

Pittsburgh

Dr. Hospitalist responds: Several thoughts came to my mind when I read your question. What did you mean by the term “bouncing”? When you refer to “nonteaching service,” are you referring to the cohort of inpatients in your teaching hospital cared for by attending physicians without the involvement of trainees? Of course, the most obvious question is what is causing your “doubt”?

As you may know, all U.S. postgraduate physician training programs are governed by the rules and standards set forth by the Accreditation Council for Graduate Medical Education (ACGME). You can find all of ACGME’s rules online at www.acgme.org. Regardless of whether you are a trainee or an attending physician, the ACGME expects the same interpretation and enforcement of their standards.

Our general medical service is divided into the resident-covered service and a separate, nonresident-covered service. Resident-covered service means IM residents are involved in the care of the patient under the supervision of an attending physician. No residents are involved in patient care on the nonresident-covered service. The development of our nonresident-covered service was clearly a product of ACGME duty-hour standards, which were originally enacted in 2003 and recently revised.

Our IM program has the same number of residents that we did before the new rules were put in place. Before 2003, we did not have a nonresident-covered medical service because we had a sufficient number of residents to care for all patients on our medical service. We found that the 2003 standards restricted the number of hours our residents could work in our hospital, so despite no change in the size of our medical service or the number of residents, we found ourselves without sufficient numbers of residents to meet the clinical demand. To meet this demand, we developed a hospitalist-run, nonresident-covered medical service.

We discussed a number of issues during the planning stages of our new service:

• How many hospitalist full-time equivalents (FTEs) would we need to staff this service?
• Would we have hospitalists physically in the hospital 24/7 or take call from outside the hospital?
• How much would it cost?
• Do we have two groups of hospitalist staff, one for the resident-covered service and a separate one for the nonresident-covered service? Or do we maintain one cohort of hospitalists and ask the staff to work on both the resident- and nonresident-covered services?
• Do we ask our hospitalists to rotate month by month or week by week, separately on the resident- and then the nonresident-covered service? Or do we ask hospitalists to see both patients on any given day?
• Do we geographically cohort our resident-covered patients on floors separate from our nonresident-covered patients?

The new rules fueled a lot of discussion between educators and trainees. Your question about the transfer of patients between resident- and nonresident-covered services does not surprise me. Some training programs tried to minimize the necessary number of attending level staff in the hospital by allowing trainees to “cross-cover,” or essentially care for patients on the nonresident-covered service, when the attending staff was not present in the hospital. It is my understanding that trainees are never allowed to cross-cover patients on the nonresident-covered service.

To my knowledge, however, there are no rules against transferring patients from the nonresident-covered service to the resident-covered service, or vice versa. TH

I have doubts: Are there any guidelines about “bouncing” patients between teaching and nonteaching services in a teaching hospital?

Srikanth Seethala, MD

Pittsburgh

Dr. Hospitalist responds: Several thoughts came to my mind when I read your question. What did you mean by the term “bouncing”? When you refer to “nonteaching service,” are you referring to the cohort of inpatients in your teaching hospital cared for by attending physicians without the involvement of trainees? Of course, the most obvious question is what is causing your “doubt”?

As you may know, all U.S. postgraduate physician training programs are governed by the rules and standards set forth by the Accreditation Council for Graduate Medical Education (ACGME). You can find all of ACGME’s rules online at www.acgme.org. Regardless of whether you are a trainee or an attending physician, the ACGME expects the same interpretation and enforcement of their standards.

Our general medical service is divided into the resident-covered service and a separate, nonresident-covered service. Resident-covered service means IM residents are involved in the care of the patient under the supervision of an attending physician. No residents are involved in patient care on the nonresident-covered service. The development of our nonresident-covered service was clearly a product of ACGME duty-hour standards, which were originally enacted in 2003 and recently revised.

Our IM program has the same number of residents that we did before the new rules were put in place. Before 2003, we did not have a nonresident-covered medical service because we had a sufficient number of residents to care for all patients on our medical service. We found that the 2003 standards restricted the number of hours our residents could work in our hospital, so despite no change in the size of our medical service or the number of residents, we found ourselves without sufficient numbers of residents to meet the clinical demand. To meet this demand, we developed a hospitalist-run, nonresident-covered medical service.

We discussed a number of issues during the planning stages of our new service:

• How many hospitalist full-time equivalents (FTEs) would we need to staff this service?
• Would we have hospitalists physically in the hospital 24/7 or take call from outside the hospital?
• How much would it cost?
• Do we have two groups of hospitalist staff, one for the resident-covered service and a separate one for the nonresident-covered service? Or do we maintain one cohort of hospitalists and ask the staff to work on both the resident- and nonresident-covered services?
• Do we ask our hospitalists to rotate month by month or week by week, separately on the resident- and then the nonresident-covered service? Or do we ask hospitalists to see both patients on any given day?
• Do we geographically cohort our resident-covered patients on floors separate from our nonresident-covered patients?

The new rules fueled a lot of discussion between educators and trainees. Your question about the transfer of patients between resident- and nonresident-covered services does not surprise me. Some training programs tried to minimize the necessary number of attending level staff in the hospital by allowing trainees to “cross-cover,” or essentially care for patients on the nonresident-covered service, when the attending staff was not present in the hospital. It is my understanding that trainees are never allowed to cross-cover patients on the nonresident-covered service.

To my knowledge, however, there are no rules against transferring patients from the nonresident-covered service to the resident-covered service, or vice versa. TH

I have doubts: Are there any guidelines about “bouncing” patients between teaching and nonteaching services in a teaching hospital?

Srikanth Seethala, MD

Pittsburgh

Dr. Hospitalist responds: Several thoughts came to my mind when I read your question. What did you mean by the term “bouncing”? When you refer to “nonteaching service,” are you referring to the cohort of inpatients in your teaching hospital cared for by attending physicians without the involvement of trainees? Of course, the most obvious question is what is causing your “doubt”?

As you may know, all U.S. postgraduate physician training programs are governed by the rules and standards set forth by the Accreditation Council for Graduate Medical Education (ACGME). You can find all of ACGME’s rules online at www.acgme.org. Regardless of whether you are a trainee or an attending physician, the ACGME expects the same interpretation and enforcement of their standards.

Our general medical service is divided into the resident-covered service and a separate, nonresident-covered service. Resident-covered service means IM residents are involved in the care of the patient under the supervision of an attending physician. No residents are involved in patient care on the nonresident-covered service. The development of our nonresident-covered service was clearly a product of ACGME duty-hour standards, which were originally enacted in 2003 and recently revised.

Our IM program has the same number of residents that we did before the new rules were put in place. Before 2003, we did not have a nonresident-covered medical service because we had a sufficient number of residents to care for all patients on our medical service. We found that the 2003 standards restricted the number of hours our residents could work in our hospital, so despite no change in the size of our medical service or the number of residents, we found ourselves without sufficient numbers of residents to meet the clinical demand. To meet this demand, we developed a hospitalist-run, nonresident-covered medical service.

We discussed a number of issues during the planning stages of our new service:

• How many hospitalist full-time equivalents (FTEs) would we need to staff this service?
• Would we have hospitalists physically in the hospital 24/7 or take call from outside the hospital?
• How much would it cost?
• Do we have two groups of hospitalist staff, one for the resident-covered service and a separate one for the nonresident-covered service? Or do we maintain one cohort of hospitalists and ask the staff to work on both the resident- and nonresident-covered services?
• Do we ask our hospitalists to rotate month by month or week by week, separately on the resident- and then the nonresident-covered service? Or do we ask hospitalists to see both patients on any given day?
• Do we geographically cohort our resident-covered patients on floors separate from our nonresident-covered patients?

The new rules fueled a lot of discussion between educators and trainees. Your question about the transfer of patients between resident- and nonresident-covered services does not surprise me. Some training programs tried to minimize the necessary number of attending level staff in the hospital by allowing trainees to “cross-cover,” or essentially care for patients on the nonresident-covered service, when the attending staff was not present in the hospital. It is my understanding that trainees are never allowed to cross-cover patients on the nonresident-covered service.

To my knowledge, however, there are no rules against transferring patients from the nonresident-covered service to the resident-covered service, or vice versa. TH

Focused Practice in Hospital Medicine Worth the Additional Cost

Why are we being required to fork over an extra $380 for the Focused Practice in Hospital Medicine MOC? This feels like the icing on the cake of already a major ripoff.

Dr. Ragan

Grass Valley, Calif.

Dr. Hospitalist responds: Thank you for your frank reaction to the much-anticipated American Board of Internal Medicine (ABIM) Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program. As you noted, an additional fee is required to participate in this recertification program.

To my knowledge, any and all fees associated with recertification are paid to ABIM. No other organization benefits from the added cost, so your question might be more appropriately addressed to ABIM (see “Focused Practice in Hospital Medicine,” May 2010, p. 1). But because you asked the question, I am happy to respond with my thoughts.

Participation in the FPHM MOC program is not mandatory. I am not aware of any organization that is requiring hospitalists to participate. I don’t expect that your lack of participation will affect your ability to obtain hospital privileges. Like any new MOC program, I would expect some up-front administrative costs associated with developing and administering the practice-improvement modules and the secure examination.

It’s up to you and others to decide whether this added recognition is worth the cost. I can tell you that I have made the decision to participate. I fully expect to be part of the inaugural class of ABIM diplomates with this added recognition by the end of the year.

What went into my own decision to participate? I can tell you that I am a practicing hospitalist who makes a salary typical of most hospitalists. I am frugal with my money and certainly do not view the added cost as an insignificant amount of money. Like most hospitalists, I am not only busy with my professional life, but I have plenty of family commitments as well.

I expect the exam will be rigorous, and the requirements of the practice-improvement modules will be demanding. I would not want it any other way. In the fast-changing healthcare environment, I believe that hospitalists will be challenged to think about what it means to care for a hospitalized patient. To succeed in the future, hospitalists will be expected to not only participate, but also lead QI efforts at their institutions. The FPHM MOC will distinguish me as a hospitalist with added qualifications in the field of QI.

So how about it, Dr. Ragan? Will you join me?

What Certification Requirements Should a Hospitalist Program Have for Its Physicians?

I hope you can help me with some questions I have concerning starting a hospitalist program at my medical center. Are there certain requirements (e.g., board certification in internal medicine, ACLS, etc.) that need to be met, or is that up to the facility? The physician interested in the position is board-certified in infectious disease. Any direction you can give me on this would be greatly appreciated.

Marisa Sellers,

Medical Staff Coordinator,

Hartselle Medical Center,

Hartselle, Ala.

Dr. Hospitalist responds: Congratulations on your medical center’s decision to establish a hospitalist program. Over the past decade, HM has been the fastest-growing field in all of American medicine. The majority of the country’s acute-care hospitals have hospitalists on staff.

Approximately 85% of the country’s hospitalists received training in internal medicine. Most of the other hospitalists received training in pediatrics or family medicine. While most hospitalists are general internists, some also have additional subspecialty training, which seems to be the case of the physician at your medical center. As you know, different medical facilities have different requirements of their medical staff. At the acute-care hospital where I work clinically, maintenance of board certification is required of all medical staff. I know that is not the case for all hospitals, yet I’m not aware of any hospitals with hospitalist-specific medical staff requirements.

Most of the hospitalists who are internists will be either board-eligible or board-certified with the American Board of Internal Medicine (ABIM). You should be aware that ABIM has developed a new program, the Recognition of Focused Practice (RFP) in Hospital Medicine. As part of this maintenance of certification (MOC) program, ABIM diplomates will have the opportunity to take the first ABIM Hospital Medicine examination in October. For more information about this exam, ABIM’s rationale for recognizing a focused practice in HM, and any other questions about this program, please visit the ABIM Web site at www.abim.org/news/news/focused-

practice-hospital-medicine-qa.aspx.

I have heard from hospitalists trained as family physicians who are interested in RFP as hospitalists. It is my understanding that the American Board of Family Medicine is studying the ABIM program and working to develop a similar program for hospitalists with family medicine board certifications.

Regarding your question about hospitalists and the American Heart Association’s advanced cardiac life support (ACLS) training and certification: While I think it is a great idea for hospitalists to receive this training and maintain this certification, I am not aware of any mandate for hospitalists to be uniformly ACLS-certified. I think this is an issue the medical staff at your medical center will have to decide; basically, what is in the best interests of your patients?

Focused Practice in Hospital Medicine Worth the Additional Cost

Why are we being required to fork over an extra $380 for the Focused Practice in Hospital Medicine MOC? This feels like the icing on the cake of already a major ripoff.

Dr. Ragan

Grass Valley, Calif.

Dr. Hospitalist responds: Thank you for your frank reaction to the much-anticipated American Board of Internal Medicine (ABIM) Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program. As you noted, an additional fee is required to participate in this recertification program.

To my knowledge, any and all fees associated with recertification are paid to ABIM. No other organization benefits from the added cost, so your question might be more appropriately addressed to ABIM (see “Focused Practice in Hospital Medicine,” May 2010, p. 1). But because you asked the question, I am happy to respond with my thoughts.

Participation in the FPHM MOC program is not mandatory. I am not aware of any organization that is requiring hospitalists to participate. I don’t expect that your lack of participation will affect your ability to obtain hospital privileges. Like any new MOC program, I would expect some up-front administrative costs associated with developing and administering the practice-improvement modules and the secure examination.

It’s up to you and others to decide whether this added recognition is worth the cost. I can tell you that I have made the decision to participate. I fully expect to be part of the inaugural class of ABIM diplomates with this added recognition by the end of the year.

What went into my own decision to participate? I can tell you that I am a practicing hospitalist who makes a salary typical of most hospitalists. I am frugal with my money and certainly do not view the added cost as an insignificant amount of money. Like most hospitalists, I am not only busy with my professional life, but I have plenty of family commitments as well.

I expect the exam will be rigorous, and the requirements of the practice-improvement modules will be demanding. I would not want it any other way. In the fast-changing healthcare environment, I believe that hospitalists will be challenged to think about what it means to care for a hospitalized patient. To succeed in the future, hospitalists will be expected to not only participate, but also lead QI efforts at their institutions. The FPHM MOC will distinguish me as a hospitalist with added qualifications in the field of QI.

So how about it, Dr. Ragan? Will you join me?

What Certification Requirements Should a Hospitalist Program Have for Its Physicians?

I hope you can help me with some questions I have concerning starting a hospitalist program at my medical center. Are there certain requirements (e.g., board certification in internal medicine, ACLS, etc.) that need to be met, or is that up to the facility? The physician interested in the position is board-certified in infectious disease. Any direction you can give me on this would be greatly appreciated.

Marisa Sellers,

Medical Staff Coordinator,

Hartselle Medical Center,

Hartselle, Ala.

Dr. Hospitalist responds: Congratulations on your medical center’s decision to establish a hospitalist program. Over the past decade, HM has been the fastest-growing field in all of American medicine. The majority of the country’s acute-care hospitals have hospitalists on staff.

Approximately 85% of the country’s hospitalists received training in internal medicine. Most of the other hospitalists received training in pediatrics or family medicine. While most hospitalists are general internists, some also have additional subspecialty training, which seems to be the case of the physician at your medical center. As you know, different medical facilities have different requirements of their medical staff. At the acute-care hospital where I work clinically, maintenance of board certification is required of all medical staff. I know that is not the case for all hospitals, yet I’m not aware of any hospitals with hospitalist-specific medical staff requirements.

Most of the hospitalists who are internists will be either board-eligible or board-certified with the American Board of Internal Medicine (ABIM). You should be aware that ABIM has developed a new program, the Recognition of Focused Practice (RFP) in Hospital Medicine. As part of this maintenance of certification (MOC) program, ABIM diplomates will have the opportunity to take the first ABIM Hospital Medicine examination in October. For more information about this exam, ABIM’s rationale for recognizing a focused practice in HM, and any other questions about this program, please visit the ABIM Web site at www.abim.org/news/news/focused-

practice-hospital-medicine-qa.aspx.

I have heard from hospitalists trained as family physicians who are interested in RFP as hospitalists. It is my understanding that the American Board of Family Medicine is studying the ABIM program and working to develop a similar program for hospitalists with family medicine board certifications.

Regarding your question about hospitalists and the American Heart Association’s advanced cardiac life support (ACLS) training and certification: While I think it is a great idea for hospitalists to receive this training and maintain this certification, I am not aware of any mandate for hospitalists to be uniformly ACLS-certified. I think this is an issue the medical staff at your medical center will have to decide; basically, what is in the best interests of your patients?

Focused Practice in Hospital Medicine Worth the Additional Cost

Why are we being required to fork over an extra $380 for the Focused Practice in Hospital Medicine MOC? This feels like the icing on the cake of already a major ripoff.

Dr. Ragan

Grass Valley, Calif.

Dr. Hospitalist responds: Thank you for your frank reaction to the much-anticipated American Board of Internal Medicine (ABIM) Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program. As you noted, an additional fee is required to participate in this recertification program.

To my knowledge, any and all fees associated with recertification are paid to ABIM. No other organization benefits from the added cost, so your question might be more appropriately addressed to ABIM (see “Focused Practice in Hospital Medicine,” May 2010, p. 1). But because you asked the question, I am happy to respond with my thoughts.

Participation in the FPHM MOC program is not mandatory. I am not aware of any organization that is requiring hospitalists to participate. I don’t expect that your lack of participation will affect your ability to obtain hospital privileges. Like any new MOC program, I would expect some up-front administrative costs associated with developing and administering the practice-improvement modules and the secure examination.

It’s up to you and others to decide whether this added recognition is worth the cost. I can tell you that I have made the decision to participate. I fully expect to be part of the inaugural class of ABIM diplomates with this added recognition by the end of the year.

What went into my own decision to participate? I can tell you that I am a practicing hospitalist who makes a salary typical of most hospitalists. I am frugal with my money and certainly do not view the added cost as an insignificant amount of money. Like most hospitalists, I am not only busy with my professional life, but I have plenty of family commitments as well.

I expect the exam will be rigorous, and the requirements of the practice-improvement modules will be demanding. I would not want it any other way. In the fast-changing healthcare environment, I believe that hospitalists will be challenged to think about what it means to care for a hospitalized patient. To succeed in the future, hospitalists will be expected to not only participate, but also lead QI efforts at their institutions. The FPHM MOC will distinguish me as a hospitalist with added qualifications in the field of QI.

So how about it, Dr. Ragan? Will you join me?

What Certification Requirements Should a Hospitalist Program Have for Its Physicians?

I hope you can help me with some questions I have concerning starting a hospitalist program at my medical center. Are there certain requirements (e.g., board certification in internal medicine, ACLS, etc.) that need to be met, or is that up to the facility? The physician interested in the position is board-certified in infectious disease. Any direction you can give me on this would be greatly appreciated.

Marisa Sellers,

Medical Staff Coordinator,

Hartselle Medical Center,

Hartselle, Ala.

Dr. Hospitalist responds: Congratulations on your medical center’s decision to establish a hospitalist program. Over the past decade, HM has been the fastest-growing field in all of American medicine. The majority of the country’s acute-care hospitals have hospitalists on staff.

Approximately 85% of the country’s hospitalists received training in internal medicine. Most of the other hospitalists received training in pediatrics or family medicine. While most hospitalists are general internists, some also have additional subspecialty training, which seems to be the case of the physician at your medical center. As you know, different medical facilities have different requirements of their medical staff. At the acute-care hospital where I work clinically, maintenance of board certification is required of all medical staff. I know that is not the case for all hospitals, yet I’m not aware of any hospitals with hospitalist-specific medical staff requirements.

Most of the hospitalists who are internists will be either board-eligible or board-certified with the American Board of Internal Medicine (ABIM). You should be aware that ABIM has developed a new program, the Recognition of Focused Practice (RFP) in Hospital Medicine. As part of this maintenance of certification (MOC) program, ABIM diplomates will have the opportunity to take the first ABIM Hospital Medicine examination in October. For more information about this exam, ABIM’s rationale for recognizing a focused practice in HM, and any other questions about this program, please visit the ABIM Web site at www.abim.org/news/news/focused-

practice-hospital-medicine-qa.aspx.

I have heard from hospitalists trained as family physicians who are interested in RFP as hospitalists. It is my understanding that the American Board of Family Medicine is studying the ABIM program and working to develop a similar program for hospitalists with family medicine board certifications.

Regarding your question about hospitalists and the American Heart Association’s advanced cardiac life support (ACLS) training and certification: While I think it is a great idea for hospitalists to receive this training and maintain this certification, I am not aware of any mandate for hospitalists to be uniformly ACLS-certified. I think this is an issue the medical staff at your medical center will have to decide; basically, what is in the best interests of your patients?

Physicians Could Be Eligible to Receive IRS Refund

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

J. Byrne, MD

New YorkRe

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

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

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

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

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

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

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

Is the Economy Having a Negative Effect on Hospitalist Jobs?

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

Reza Mohan, MD

Seattle

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

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

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

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

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

Reference

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

Physicians Could Be Eligible to Receive IRS Refund

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

J. Byrne, MD

New YorkRe

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

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

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

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

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

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

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

Is the Economy Having a Negative Effect on Hospitalist Jobs?

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

Reza Mohan, MD

Seattle

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

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

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

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

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

Reference

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

Physicians Could Be Eligible to Receive IRS Refund

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

J. Byrne, MD

New YorkRe

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

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

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

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

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

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

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

Is the Economy Having a Negative Effect on Hospitalist Jobs?

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

Reza Mohan, MD

Seattle

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

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

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

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

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

Reference

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

AMANE KANEKO

Effective Communication Ensures Patient Safety

Can you explain to me what is meant by SBAR? I heard this acronym mentioned during a session at HM09, but I did not understand the term.

S. East, MD

Pullman, Wash.

Dr. Hospitalist responds: SBAR (pronounced “ess-bar”) is a standardized method of communication that originated in the Navy’s nuclear submarine program. It stands for:

• Situation: What is happening presently?
• Background: What circumstances led to this situation?
• Assessment: What do I think is the problem?
• Recommendation: What should we do to correct the problem?

The SBAR system was developed to prevent simple communication errors that could lead to global disaster.

Kaiser Permanente of Colorado was among the first to adopt this model of communication among its staff and has since popularized its use in healthcare. Numerous hospitals and healthcare organizations have implemented SBAR as an approach to minimize communication errors between healthcare providers. The idea is that eliminating communication errors between healthcare providers improves patient safety. SBAR encourages all providers (doctors, nurses, pharmacists, etc.) to communicate with a shared mental model for information transfer.

SBAR requires providers to organize their thoughts, understand what it is they want to convey, and make requests in an organized fashion. Adherence to SBAR allows providers to transmit factual information in a concise manner.

Highly effective communication is essential to any hospitalist program. The SBAR approach should not be limited to nurse-doctor communication. I encourage you to implement this tool at your institution.

For more information, an SBAR toolkit is available at www.azhha.org/patient_safety/sbar.aspx. TH

AMANE KANEKO

Effective Communication Ensures Patient Safety

Can you explain to me what is meant by SBAR? I heard this acronym mentioned during a session at HM09, but I did not understand the term.

S. East, MD

Pullman, Wash.

Dr. Hospitalist responds: SBAR (pronounced “ess-bar”) is a standardized method of communication that originated in the Navy’s nuclear submarine program. It stands for:

• Situation: What is happening presently?
• Background: What circumstances led to this situation?
• Assessment: What do I think is the problem?
• Recommendation: What should we do to correct the problem?

The SBAR system was developed to prevent simple communication errors that could lead to global disaster.

Kaiser Permanente of Colorado was among the first to adopt this model of communication among its staff and has since popularized its use in healthcare. Numerous hospitals and healthcare organizations have implemented SBAR as an approach to minimize communication errors between healthcare providers. The idea is that eliminating communication errors between healthcare providers improves patient safety. SBAR encourages all providers (doctors, nurses, pharmacists, etc.) to communicate with a shared mental model for information transfer.

SBAR requires providers to organize their thoughts, understand what it is they want to convey, and make requests in an organized fashion. Adherence to SBAR allows providers to transmit factual information in a concise manner.

Highly effective communication is essential to any hospitalist program. The SBAR approach should not be limited to nurse-doctor communication. I encourage you to implement this tool at your institution.

For more information, an SBAR toolkit is available at www.azhha.org/patient_safety/sbar.aspx. TH

AMANE KANEKO

Effective Communication Ensures Patient Safety

Can you explain to me what is meant by SBAR? I heard this acronym mentioned during a session at HM09, but I did not understand the term.

S. East, MD

Pullman, Wash.

Dr. Hospitalist responds: SBAR (pronounced “ess-bar”) is a standardized method of communication that originated in the Navy’s nuclear submarine program. It stands for:

• Situation: What is happening presently?
• Background: What circumstances led to this situation?
• Assessment: What do I think is the problem?
• Recommendation: What should we do to correct the problem?

The SBAR system was developed to prevent simple communication errors that could lead to global disaster.

Kaiser Permanente of Colorado was among the first to adopt this model of communication among its staff and has since popularized its use in healthcare. Numerous hospitals and healthcare organizations have implemented SBAR as an approach to minimize communication errors between healthcare providers. The idea is that eliminating communication errors between healthcare providers improves patient safety. SBAR encourages all providers (doctors, nurses, pharmacists, etc.) to communicate with a shared mental model for information transfer.

SBAR requires providers to organize their thoughts, understand what it is they want to convey, and make requests in an organized fashion. Adherence to SBAR allows providers to transmit factual information in a concise manner.

Highly effective communication is essential to any hospitalist program. The SBAR approach should not be limited to nurse-doctor communication. I encourage you to implement this tool at your institution.

For more information, an SBAR toolkit is available at www.azhha.org/patient_safety/sbar.aspx. TH

HM groups should provide informational brochures to admitted patients

I am trying to find out two pieces of information. First, is there a national association of hospitalists that oversees and gives guidance to all of the regional and national hospitalists that are now in practice? If this defines your group, great. On to my second question: Is there an established policy or doctrine that is recommended for hospitals in regard to disclosure to patients that they are indeed a hospitalist type of hospital? If so, could you advise how I might obtain a written copy? Thank you.

C.G. Lemaire, Virginia

Dr. Hospitalist responds: According to the 2008 American Hospital Association survey, about half of the nation’s hospitals have hospitalists. In hospitals with 200 or more beds, 83% have hospitalists. The field has grown rapidly since its inception in the late 1990s. There are an estimated 28,000 hospitalists in the U.S.

Most hospitalists recognize the Society of Hospital Medicine (SHM) as the professional society that represents their interests. I am not aware of any established SHM policy that mandates or suggests that a hospital disclose to patients the fact that hospitalists work there, nor do I believe that one is necessary. Hospitalists are medical doctors whose interest is the care of hospitalized patients. This is analogous to critical-care physicians, whose interest is care of the patients in hospital intensive-care units, or ED physicians, who care for patients in hospital emergency departments. There is neither a requirement nor expectation for hospitals to notify patients of the availability of these types of physicians working at a hospital.

I understand patient expectations can be different. Most patients expect to see ED physicians when they visit a hospital ED. But this was not always the case. Several decades ago, the field of emergency medicine was in its infancy, and most hospitals did not have ED physicians. I am certain most patients were surprised to see an ED physician instead of their primary-care physician (PCP). But patients came to realize ED physicians were trained specifically to care for ED patients and were available to care for them when their PCP was not available. I think patients will become familiar with hospitalists and expect to see one when they are hospitalized—but until that time arrives, I do think it is reasonable for everyone involved to help set that expectation for patients.

Ideally, HM programs should develop brochures explaining a hospitalist’s role in the care of hospitalized patients, as well as the relationship between hospitalists and PCPs (see “Satisfaction Scorecard,” January 2009, p. 57). These brochures should be distributed not only to hospitalized patients, but to outpatients in PCP offices. The primary-care clinic waiting room is a great place for these brochures.

PCPs should discuss the role of hospitalists when they send a patient to the hospital for admission. It is important for hospitalists and PCPs to know that patients are more likely to be accepting if they understand: 1) the PCP supports this model of care; 2) the hospitalist and PCP are communicating about the patient’s care; and 3) the hospitalist is available to the patient while the PCP is in their clinic.

SHM’s Web site also has a sample brochure, which can be used to introduce and inform patients about the hospitalists’ role in their care. Download the form at www.hospitalmedicine.org/samplebrochure.

Know your contract before signing the dotted line

My contract says that as a hospitalist, I will work 18 shifts a month, each being a nine-hour duration, and on average 2,000 hours per year. It does not add up to 2,000 hours. Does night call count toward the number of hours? Do weekends and holidays count toward the number of hours?

Anshu Sood, MD

Dr. Hospitalist responds: If I understand you correctly, you are working 1,944 hours annually (18 shifts per month x 12 months x nine hours per shift). You did not tell me whether your compensation is based on the number of hours you work or whether you collect a salary regardless of the number of hours you work. If you collect a salary, sounds like you are scheduled to work fewer hours than expected.

That being said, I also don’t know the other details of your employment agreement. Does your employment agreement include paid vacation and sick time? Perhaps that might explain the difference. Another plausible explanation is that your compensation includes payment for sign-out and sign-in time at the beginning and end of each shift (18 shifts/month x 12 months x 9.25 hours/shift = 1,998 hours). Regardless of the explanation, your question made me wonder: Why are the details of your job description unclear to you, and why are you asking me rather than your employer for clarification? I urge all hospitalists to clearly understand their employment agreements before accepting any job offer. Any differences should be resolved before signing the contract. It is worth the time and money to seek the advice of an attorney familiar with physician employment contracts. The attorney’s job is to review your agreement and explain the terms of the contract, as well as point out what is missing. TH

HM groups should provide informational brochures to admitted patients

I am trying to find out two pieces of information. First, is there a national association of hospitalists that oversees and gives guidance to all of the regional and national hospitalists that are now in practice? If this defines your group, great. On to my second question: Is there an established policy or doctrine that is recommended for hospitals in regard to disclosure to patients that they are indeed a hospitalist type of hospital? If so, could you advise how I might obtain a written copy? Thank you.

C.G. Lemaire, Virginia

Dr. Hospitalist responds: According to the 2008 American Hospital Association survey, about half of the nation’s hospitals have hospitalists. In hospitals with 200 or more beds, 83% have hospitalists. The field has grown rapidly since its inception in the late 1990s. There are an estimated 28,000 hospitalists in the U.S.

Most hospitalists recognize the Society of Hospital Medicine (SHM) as the professional society that represents their interests. I am not aware of any established SHM policy that mandates or suggests that a hospital disclose to patients the fact that hospitalists work there, nor do I believe that one is necessary. Hospitalists are medical doctors whose interest is the care of hospitalized patients. This is analogous to critical-care physicians, whose interest is care of the patients in hospital intensive-care units, or ED physicians, who care for patients in hospital emergency departments. There is neither a requirement nor expectation for hospitals to notify patients of the availability of these types of physicians working at a hospital.

I understand patient expectations can be different. Most patients expect to see ED physicians when they visit a hospital ED. But this was not always the case. Several decades ago, the field of emergency medicine was in its infancy, and most hospitals did not have ED physicians. I am certain most patients were surprised to see an ED physician instead of their primary-care physician (PCP). But patients came to realize ED physicians were trained specifically to care for ED patients and were available to care for them when their PCP was not available. I think patients will become familiar with hospitalists and expect to see one when they are hospitalized—but until that time arrives, I do think it is reasonable for everyone involved to help set that expectation for patients.

Ideally, HM programs should develop brochures explaining a hospitalist’s role in the care of hospitalized patients, as well as the relationship between hospitalists and PCPs (see “Satisfaction Scorecard,” January 2009, p. 57). These brochures should be distributed not only to hospitalized patients, but to outpatients in PCP offices. The primary-care clinic waiting room is a great place for these brochures.

PCPs should discuss the role of hospitalists when they send a patient to the hospital for admission. It is important for hospitalists and PCPs to know that patients are more likely to be accepting if they understand: 1) the PCP supports this model of care; 2) the hospitalist and PCP are communicating about the patient’s care; and 3) the hospitalist is available to the patient while the PCP is in their clinic.

SHM’s Web site also has a sample brochure, which can be used to introduce and inform patients about the hospitalists’ role in their care. Download the form at www.hospitalmedicine.org/samplebrochure.

Know your contract before signing the dotted line

My contract says that as a hospitalist, I will work 18 shifts a month, each being a nine-hour duration, and on average 2,000 hours per year. It does not add up to 2,000 hours. Does night call count toward the number of hours? Do weekends and holidays count toward the number of hours?

Anshu Sood, MD

Dr. Hospitalist responds: If I understand you correctly, you are working 1,944 hours annually (18 shifts per month x 12 months x nine hours per shift). You did not tell me whether your compensation is based on the number of hours you work or whether you collect a salary regardless of the number of hours you work. If you collect a salary, sounds like you are scheduled to work fewer hours than expected.

That being said, I also don’t know the other details of your employment agreement. Does your employment agreement include paid vacation and sick time? Perhaps that might explain the difference. Another plausible explanation is that your compensation includes payment for sign-out and sign-in time at the beginning and end of each shift (18 shifts/month x 12 months x 9.25 hours/shift = 1,998 hours). Regardless of the explanation, your question made me wonder: Why are the details of your job description unclear to you, and why are you asking me rather than your employer for clarification? I urge all hospitalists to clearly understand their employment agreements before accepting any job offer. Any differences should be resolved before signing the contract. It is worth the time and money to seek the advice of an attorney familiar with physician employment contracts. The attorney’s job is to review your agreement and explain the terms of the contract, as well as point out what is missing. TH

HM groups should provide informational brochures to admitted patients

I am trying to find out two pieces of information. First, is there a national association of hospitalists that oversees and gives guidance to all of the regional and national hospitalists that are now in practice? If this defines your group, great. On to my second question: Is there an established policy or doctrine that is recommended for hospitals in regard to disclosure to patients that they are indeed a hospitalist type of hospital? If so, could you advise how I might obtain a written copy? Thank you.

C.G. Lemaire, Virginia

Dr. Hospitalist responds: According to the 2008 American Hospital Association survey, about half of the nation’s hospitals have hospitalists. In hospitals with 200 or more beds, 83% have hospitalists. The field has grown rapidly since its inception in the late 1990s. There are an estimated 28,000 hospitalists in the U.S.

Most hospitalists recognize the Society of Hospital Medicine (SHM) as the professional society that represents their interests. I am not aware of any established SHM policy that mandates or suggests that a hospital disclose to patients the fact that hospitalists work there, nor do I believe that one is necessary. Hospitalists are medical doctors whose interest is the care of hospitalized patients. This is analogous to critical-care physicians, whose interest is care of the patients in hospital intensive-care units, or ED physicians, who care for patients in hospital emergency departments. There is neither a requirement nor expectation for hospitals to notify patients of the availability of these types of physicians working at a hospital.

I understand patient expectations can be different. Most patients expect to see ED physicians when they visit a hospital ED. But this was not always the case. Several decades ago, the field of emergency medicine was in its infancy, and most hospitals did not have ED physicians. I am certain most patients were surprised to see an ED physician instead of their primary-care physician (PCP). But patients came to realize ED physicians were trained specifically to care for ED patients and were available to care for them when their PCP was not available. I think patients will become familiar with hospitalists and expect to see one when they are hospitalized—but until that time arrives, I do think it is reasonable for everyone involved to help set that expectation for patients.

Ideally, HM programs should develop brochures explaining a hospitalist’s role in the care of hospitalized patients, as well as the relationship between hospitalists and PCPs (see “Satisfaction Scorecard,” January 2009, p. 57). These brochures should be distributed not only to hospitalized patients, but to outpatients in PCP offices. The primary-care clinic waiting room is a great place for these brochures.

PCPs should discuss the role of hospitalists when they send a patient to the hospital for admission. It is important for hospitalists and PCPs to know that patients are more likely to be accepting if they understand: 1) the PCP supports this model of care; 2) the hospitalist and PCP are communicating about the patient’s care; and 3) the hospitalist is available to the patient while the PCP is in their clinic.

SHM’s Web site also has a sample brochure, which can be used to introduce and inform patients about the hospitalists’ role in their care. Download the form at www.hospitalmedicine.org/samplebrochure.

Know your contract before signing the dotted line

My contract says that as a hospitalist, I will work 18 shifts a month, each being a nine-hour duration, and on average 2,000 hours per year. It does not add up to 2,000 hours. Does night call count toward the number of hours? Do weekends and holidays count toward the number of hours?

Anshu Sood, MD

Dr. Hospitalist responds: If I understand you correctly, you are working 1,944 hours annually (18 shifts per month x 12 months x nine hours per shift). You did not tell me whether your compensation is based on the number of hours you work or whether you collect a salary regardless of the number of hours you work. If you collect a salary, sounds like you are scheduled to work fewer hours than expected.

That being said, I also don’t know the other details of your employment agreement. Does your employment agreement include paid vacation and sick time? Perhaps that might explain the difference. Another plausible explanation is that your compensation includes payment for sign-out and sign-in time at the beginning and end of each shift (18 shifts/month x 12 months x 9.25 hours/shift = 1,998 hours). Regardless of the explanation, your question made me wonder: Why are the details of your job description unclear to you, and why are you asking me rather than your employer for clarification? I urge all hospitalists to clearly understand their employment agreements before accepting any job offer. Any differences should be resolved before signing the contract. It is worth the time and money to seek the advice of an attorney familiar with physician employment contracts. The attorney’s job is to review your agreement and explain the terms of the contract, as well as point out what is missing. TH

Delirium Dilemma

I heard that Medicare is thinking about not paying the hospital if a hospitalized patient develops delirium. I am a geriatric hospitalist and unfortunately, this is a common problem in my patient population. This doesn’t sound reasonable. Is this really true?

Delirious in Denver

Dr. Hospitalist responds: For those of you who read this column regularly, you have seen me comment in the past about hospital acquired conditions.

In 2005, Congress authorized the Center for Medicare and Medicaid Services (CMS) to adjust hospital payments to encourage prevention of hospital acquired conditions. This was “part of an array of Medicare value-based purchasing tools that CMS is using to promote increased quality and efficiency of care.”

In August 2007, CMS announced that starting Oct. 1, 2007, hospitals were required to submit information on Medicare claims regarding whether a list of specific diagnoses were present on admission (POA). CMS was trying to determine how often patients were developing specific complications while they were hospitalized. This list of conditions included a foreign object retained after surgery, air embolism, blood incompatibility, stage three and four pressure ulcers, injuries due to falls/trauma, catheter-associated urinary tract infections, vascular catheter-associated infection and mediastinitis after coronary artery bypass graft.

They also announced that beginning Oct. 1, CMS will pay hospitals as though that complication did not occur (i.e., not pay for the additional costs associated with managing these complications). These policy changes sent hospital administrators scrambling to develop and implement plans to prevent these types of incidents from occurring in hospitalized patients.

CMS has continued to work with the Centers for Disease Control and Prevention (CDC) and other stakeholders to identify additional hospital acquired conditions. In April, CMS proposed to make the following list of conditions subject to the POA payment provision in fiscal year 2009. These include:

• Legionnaires’ disease;
• Iatrogenic pneumothorax;
• Ventilator-associated pneumonia;
• Deep-vein thrombosis (DVT/ pulmonary embolism(PE);
• Staphylococcus aureus septicemia;
• Clostridium Difficile-associated disease;
• Surgical site infections following several elective surgeries (total knee replacement, laparoscopic gastric bypass and gastroenerostomy, ligation, and stripping of varicose veins);
• Several conditions regarding glycemic control in hospitalized patients (diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma, and hypoglycemic coma); and
• Delirium.

Last year, when I heard CMS was going to stop paying for the cost of care associated with errors like transfusing the wrong type of blood and leaving foreign objects in patients during surgery, I cheered. The policy was long overdue. At present, I share your concerns when I look at this list of proposed hospital acquired conditions for fiscal year 2009.

I have no problems with CMS not paying for the costs of caring for a patient if a patient slips into a diabetic coma during his or her hospital stay. Careful monitoring and adherence to evidence based guidelines should prevent that. But I agree with you, can we really prevent delirium in all our hospitalized patients?

I took care of a patient recently with known dementia who developed delirium after her hip surgery. Dementia, surgery, and medications are known risk factors for delirium. Despite careful monitoring and thoughtful care, she was delirious after the surgery. Was I surprised? No. Could I have done more to prevent delirium? No. Why should the hospital be punished in this case? It shouldn’t. The patient needed the surgery, and I wasn’t going to withhold the narcotics just to minimize the risk of delirium. I suspect there is room for improvement in our hospitals when it comes to caring for vulnerable populations of patients. We can likely reduce the rates of delirium in our hospitalized patients, but I doubt we can truly prevent all delirium.

CMS published its proposal in April, well in advance of the new fiscal year that begins in October, because CMS is interested in seeking public comments on “the degree to which (each condition) is reasonably preventable through the application of evidence-based guidelines.”

Based on public comment, CMS will choose to select or not select each condition listed as a hospital-acquired condition. CMS is expected to make its decision known by the end of this month. Let it be known that this hospitalist is opposed to the delirium measure. I am not alone. A number of professional societies, including SHM, American College of Chest Physicians, Society of Critical Care Medicine, American Thoracic Society, among others, have expressed reservations to CMS about several of the proposed hospital-acquired conditions.

These societies believe ventilator-associated pneumonia, DVT/PE, and iatrogenic pneumothorax also should not be included as hospital-acquired conditions because they, like delirium, are not entirely preventable. Further, they believe the incidence of these four conditions can be reduced by adherence to evidence based guidelines but there is insufficient evidence to guide prevention of these conditions.

In addition, SHM raised concern that listing Legionnaires’ disease as a hospital-acquired condition may lead to unintended consequences, such as routine testing for Legionnaires’ in all patients presenting with community acquired pneumonia.

We won’t know until the end of this month whether CMS will make any or all of these conditions subject to the POA payment provision in fiscal year 2009. But kudos to the professional societies and all who have helped CMS think about these important issues. TH

Delirium Dilemma

I heard that Medicare is thinking about not paying the hospital if a hospitalized patient develops delirium. I am a geriatric hospitalist and unfortunately, this is a common problem in my patient population. This doesn’t sound reasonable. Is this really true?

Delirious in Denver

Dr. Hospitalist responds: For those of you who read this column regularly, you have seen me comment in the past about hospital acquired conditions.

In 2005, Congress authorized the Center for Medicare and Medicaid Services (CMS) to adjust hospital payments to encourage prevention of hospital acquired conditions. This was “part of an array of Medicare value-based purchasing tools that CMS is using to promote increased quality and efficiency of care.”

In August 2007, CMS announced that starting Oct. 1, 2007, hospitals were required to submit information on Medicare claims regarding whether a list of specific diagnoses were present on admission (POA). CMS was trying to determine how often patients were developing specific complications while they were hospitalized. This list of conditions included a foreign object retained after surgery, air embolism, blood incompatibility, stage three and four pressure ulcers, injuries due to falls/trauma, catheter-associated urinary tract infections, vascular catheter-associated infection and mediastinitis after coronary artery bypass graft.

They also announced that beginning Oct. 1, CMS will pay hospitals as though that complication did not occur (i.e., not pay for the additional costs associated with managing these complications). These policy changes sent hospital administrators scrambling to develop and implement plans to prevent these types of incidents from occurring in hospitalized patients.

CMS has continued to work with the Centers for Disease Control and Prevention (CDC) and other stakeholders to identify additional hospital acquired conditions. In April, CMS proposed to make the following list of conditions subject to the POA payment provision in fiscal year 2009. These include:

• Legionnaires’ disease;
• Iatrogenic pneumothorax;
• Ventilator-associated pneumonia;
• Deep-vein thrombosis (DVT/ pulmonary embolism(PE);
• Staphylococcus aureus septicemia;
• Clostridium Difficile-associated disease;
• Surgical site infections following several elective surgeries (total knee replacement, laparoscopic gastric bypass and gastroenerostomy, ligation, and stripping of varicose veins);
• Several conditions regarding glycemic control in hospitalized patients (diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma, and hypoglycemic coma); and
• Delirium.

Last year, when I heard CMS was going to stop paying for the cost of care associated with errors like transfusing the wrong type of blood and leaving foreign objects in patients during surgery, I cheered. The policy was long overdue. At present, I share your concerns when I look at this list of proposed hospital acquired conditions for fiscal year 2009.

I have no problems with CMS not paying for the costs of caring for a patient if a patient slips into a diabetic coma during his or her hospital stay. Careful monitoring and adherence to evidence based guidelines should prevent that. But I agree with you, can we really prevent delirium in all our hospitalized patients?

I took care of a patient recently with known dementia who developed delirium after her hip surgery. Dementia, surgery, and medications are known risk factors for delirium. Despite careful monitoring and thoughtful care, she was delirious after the surgery. Was I surprised? No. Could I have done more to prevent delirium? No. Why should the hospital be punished in this case? It shouldn’t. The patient needed the surgery, and I wasn’t going to withhold the narcotics just to minimize the risk of delirium. I suspect there is room for improvement in our hospitals when it comes to caring for vulnerable populations of patients. We can likely reduce the rates of delirium in our hospitalized patients, but I doubt we can truly prevent all delirium.

CMS published its proposal in April, well in advance of the new fiscal year that begins in October, because CMS is interested in seeking public comments on “the degree to which (each condition) is reasonably preventable through the application of evidence-based guidelines.”

Based on public comment, CMS will choose to select or not select each condition listed as a hospital-acquired condition. CMS is expected to make its decision known by the end of this month. Let it be known that this hospitalist is opposed to the delirium measure. I am not alone. A number of professional societies, including SHM, American College of Chest Physicians, Society of Critical Care Medicine, American Thoracic Society, among others, have expressed reservations to CMS about several of the proposed hospital-acquired conditions.

These societies believe ventilator-associated pneumonia, DVT/PE, and iatrogenic pneumothorax also should not be included as hospital-acquired conditions because they, like delirium, are not entirely preventable. Further, they believe the incidence of these four conditions can be reduced by adherence to evidence based guidelines but there is insufficient evidence to guide prevention of these conditions.

In addition, SHM raised concern that listing Legionnaires’ disease as a hospital-acquired condition may lead to unintended consequences, such as routine testing for Legionnaires’ in all patients presenting with community acquired pneumonia.

We won’t know until the end of this month whether CMS will make any or all of these conditions subject to the POA payment provision in fiscal year 2009. But kudos to the professional societies and all who have helped CMS think about these important issues. TH

Delirium Dilemma

I heard that Medicare is thinking about not paying the hospital if a hospitalized patient develops delirium. I am a geriatric hospitalist and unfortunately, this is a common problem in my patient population. This doesn’t sound reasonable. Is this really true?

Delirious in Denver

Dr. Hospitalist responds: For those of you who read this column regularly, you have seen me comment in the past about hospital acquired conditions.

In 2005, Congress authorized the Center for Medicare and Medicaid Services (CMS) to adjust hospital payments to encourage prevention of hospital acquired conditions. This was “part of an array of Medicare value-based purchasing tools that CMS is using to promote increased quality and efficiency of care.”

In August 2007, CMS announced that starting Oct. 1, 2007, hospitals were required to submit information on Medicare claims regarding whether a list of specific diagnoses were present on admission (POA). CMS was trying to determine how often patients were developing specific complications while they were hospitalized. This list of conditions included a foreign object retained after surgery, air embolism, blood incompatibility, stage three and four pressure ulcers, injuries due to falls/trauma, catheter-associated urinary tract infections, vascular catheter-associated infection and mediastinitis after coronary artery bypass graft.

They also announced that beginning Oct. 1, CMS will pay hospitals as though that complication did not occur (i.e., not pay for the additional costs associated with managing these complications). These policy changes sent hospital administrators scrambling to develop and implement plans to prevent these types of incidents from occurring in hospitalized patients.

CMS has continued to work with the Centers for Disease Control and Prevention (CDC) and other stakeholders to identify additional hospital acquired conditions. In April, CMS proposed to make the following list of conditions subject to the POA payment provision in fiscal year 2009. These include:

• Legionnaires’ disease;
• Iatrogenic pneumothorax;
• Ventilator-associated pneumonia;
• Deep-vein thrombosis (DVT/ pulmonary embolism(PE);
• Staphylococcus aureus septicemia;
• Clostridium Difficile-associated disease;
• Surgical site infections following several elective surgeries (total knee replacement, laparoscopic gastric bypass and gastroenerostomy, ligation, and stripping of varicose veins);
• Several conditions regarding glycemic control in hospitalized patients (diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma, and hypoglycemic coma); and
• Delirium.

Last year, when I heard CMS was going to stop paying for the cost of care associated with errors like transfusing the wrong type of blood and leaving foreign objects in patients during surgery, I cheered. The policy was long overdue. At present, I share your concerns when I look at this list of proposed hospital acquired conditions for fiscal year 2009.

I have no problems with CMS not paying for the costs of caring for a patient if a patient slips into a diabetic coma during his or her hospital stay. Careful monitoring and adherence to evidence based guidelines should prevent that. But I agree with you, can we really prevent delirium in all our hospitalized patients?

I took care of a patient recently with known dementia who developed delirium after her hip surgery. Dementia, surgery, and medications are known risk factors for delirium. Despite careful monitoring and thoughtful care, she was delirious after the surgery. Was I surprised? No. Could I have done more to prevent delirium? No. Why should the hospital be punished in this case? It shouldn’t. The patient needed the surgery, and I wasn’t going to withhold the narcotics just to minimize the risk of delirium. I suspect there is room for improvement in our hospitals when it comes to caring for vulnerable populations of patients. We can likely reduce the rates of delirium in our hospitalized patients, but I doubt we can truly prevent all delirium.

CMS published its proposal in April, well in advance of the new fiscal year that begins in October, because CMS is interested in seeking public comments on “the degree to which (each condition) is reasonably preventable through the application of evidence-based guidelines.”

Based on public comment, CMS will choose to select or not select each condition listed as a hospital-acquired condition. CMS is expected to make its decision known by the end of this month. Let it be known that this hospitalist is opposed to the delirium measure. I am not alone. A number of professional societies, including SHM, American College of Chest Physicians, Society of Critical Care Medicine, American Thoracic Society, among others, have expressed reservations to CMS about several of the proposed hospital-acquired conditions.

These societies believe ventilator-associated pneumonia, DVT/PE, and iatrogenic pneumothorax also should not be included as hospital-acquired conditions because they, like delirium, are not entirely preventable. Further, they believe the incidence of these four conditions can be reduced by adherence to evidence based guidelines but there is insufficient evidence to guide prevention of these conditions.

In addition, SHM raised concern that listing Legionnaires’ disease as a hospital-acquired condition may lead to unintended consequences, such as routine testing for Legionnaires’ in all patients presenting with community acquired pneumonia.

We won’t know until the end of this month whether CMS will make any or all of these conditions subject to the POA payment provision in fiscal year 2009. But kudos to the professional societies and all who have helped CMS think about these important issues. TH

Maternity Maneuvers

How do most hospitalist groups manage maternity leave? I recently took six weeks for maternity leave. My colleagues worked my shifts, and I have virtually paid them all back. To do so I often would end up working 18 to 20 days consecutively and numerous weekends. This was not ideal on many levels. I most likely will not [receive a] bonus this year as well. Is there a better way?

New Mom in Midwest

Dr. Hospitalist responds: Congratulations on the birth of your child. As you recognize, becoming a parent is a wonderful experience but also can be stressful. It is not easy to balance the competing demands of family and work.

Medical leave is not unique to hospitalists—but with the average age of hospitalists being 37, it is commonplace to have hospitalist staff start families at this stage of their lives. In fact, as a hospitalist director, it would be foolish for me not to expect and plan for maternity and paternity leaves.

Medical leaves often are stressful for hospitalist programs because of the need to find replacement staff to fill the work schedule. There is no “best” way to cover the schedule during medical leaves. One thing is certain: Not offering medical leave is not only unrealistic, it may be against the law.

Hospitalist directors and those contemplating medical leave from work should familiarize themselves with the federal government’s Family Medical Leave Act (FMLA). Of course, I’m not an attorney; anyone who is looking for accurate advice concerning FMLA and other legal matters should consult a lawyer.

Briefly stated, the FMLA requires that “covered employers must grant an eligible employee up to a total of 12 work weeks of unpaid leave during any 12-month period for one or more of the following reasons:

• Birth and care of the newborn child of the employee;
• Placement with the employee of a son or daughter for adoption or foster care;
• To care for an immediate family member (spouse, child, or parent) with a serious health condition; or
• To take medical leave when the employee is unable to work because of a serious health condition.

It is important to know that the FMLA strictly defines eligibility criteria. For example, a covered employer is one who “employs 50 or more employees for each working day during each of 20 or more calendar work weeks in the current or preceding calendar year.” There also are strict criteria that define whether one is an eligible employee. It is important to note that FMLA does not guarantee paid time off—it only requires unpaid leave. You can find additional information about the FMLA online at the government’s Web site: www.dol.gov/esa/whd/fmla.

Peer Pressure

I am an attorney who often represents physicians in hospital peer-review matters. I represent a hospitalist whom the medical staff has recommended be terminated. Two internists have been appointed to the peer-review committee; one has an office-based practice, and the other is a cardiologist. Neither is a hospitalist.

I am trying to convince the medical staff that there should be a hospitalist on the peer-review committee because I believe what a hospitalist does each day is fundamentally different in scope and patient mix than the other two internists. My argument will be much stronger if it is the case that a hospitalist’s practice is now its own medical specialty.

Can you point me to any information or articles that support my belief that hospital practice is now a separate specialty?

Anxious Attorney

Dr. Hospitalist responds: Is a hospitalist practice sufficiently different than that of an office-based internist or cardiologist, so much so that peer-review activities would necessitate at a minimum some involvement of other hospitalists? To answer this question, I think we need to understand the definition of a hospitalist.

I recently heard a doctor describe himself as a hospitalist despite working clinically in the hospital only one month annually. Is he correct in defining himself as a hospitalist? If so, how would we distinguish him from primary care doctors who spend one-twelfth of their work life caring for hospitalized patients?

SHM defines hospitalists as “physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.” Based on this definition, the doctor who spends one month annually caring for inpatients could be a hospitalist if the remainder of his work involved teaching, research, and leadership related to hospital medicine.

In your example, you cite two physicians on the peer-review committee: an office based internist and a cardiologist. Is it reasonable to consider their work similar to or different from that of a hospitalist? In the case of the internist, I think the key point is the fact you described him as office-based. That suggests to me his primary professional focus does not involve hospitalized patients.

One could argue that since both the hospitalist and the office-based internist were trained in internal medicine and both have American Board of Internal Medicine certification, they should be considered peers. I would point out that one’s specialty training has nothing to do with the definition of a hospitalist.

Although the majority of hospitalists in this country are internists, many others are family physicians and pediatricians. Some have subspecialty training, some don’t. Even obstetricians and surgeons are defining themselves as hospitalists.

With all that in mind, would we consider the cardiologist a hospitalist? Again, I think it would depend on the nature of the cardiologist practice. If this cardiologist has a primarily outpatient practice, that would be quite different from a hospitalist practice.

What if this cardiologist’s practice primarily is inpatient? I think it is reasonable to think about the scope of these physicians’ practices. Assuming the cardiologist practice is limited to the care of patients with primary cardiac issues, this would be a much narrower scope than that of most hospitalists.

It also is important to consider the training of the hospitalist. Take geriatrics hospitalists, for instance. The scope of their practice may be quite similar to that of a geriatrician who spends the majority of time caring for hospitalized patients.

Does the hospitalist have additional cardiology training? Does the focus of discussion at peer-review committee involve care of patients with primarily cardiac needs? The issue of which physicians should serve on peer-review committees when evaluating hospitalists is a complicated one that demands further scrutiny. TH

Maternity Maneuvers

How do most hospitalist groups manage maternity leave? I recently took six weeks for maternity leave. My colleagues worked my shifts, and I have virtually paid them all back. To do so I often would end up working 18 to 20 days consecutively and numerous weekends. This was not ideal on many levels. I most likely will not [receive a] bonus this year as well. Is there a better way?

New Mom in Midwest

Dr. Hospitalist responds: Congratulations on the birth of your child. As you recognize, becoming a parent is a wonderful experience but also can be stressful. It is not easy to balance the competing demands of family and work.

Medical leave is not unique to hospitalists—but with the average age of hospitalists being 37, it is commonplace to have hospitalist staff start families at this stage of their lives. In fact, as a hospitalist director, it would be foolish for me not to expect and plan for maternity and paternity leaves.

Medical leaves often are stressful for hospitalist programs because of the need to find replacement staff to fill the work schedule. There is no “best” way to cover the schedule during medical leaves. One thing is certain: Not offering medical leave is not only unrealistic, it may be against the law.

Hospitalist directors and those contemplating medical leave from work should familiarize themselves with the federal government’s Family Medical Leave Act (FMLA). Of course, I’m not an attorney; anyone who is looking for accurate advice concerning FMLA and other legal matters should consult a lawyer.

Briefly stated, the FMLA requires that “covered employers must grant an eligible employee up to a total of 12 work weeks of unpaid leave during any 12-month period for one or more of the following reasons:

• Birth and care of the newborn child of the employee;
• Placement with the employee of a son or daughter for adoption or foster care;
• To care for an immediate family member (spouse, child, or parent) with a serious health condition; or
• To take medical leave when the employee is unable to work because of a serious health condition.

It is important to know that the FMLA strictly defines eligibility criteria. For example, a covered employer is one who “employs 50 or more employees for each working day during each of 20 or more calendar work weeks in the current or preceding calendar year.” There also are strict criteria that define whether one is an eligible employee. It is important to note that FMLA does not guarantee paid time off—it only requires unpaid leave. You can find additional information about the FMLA online at the government’s Web site: www.dol.gov/esa/whd/fmla.

Peer Pressure

I am an attorney who often represents physicians in hospital peer-review matters. I represent a hospitalist whom the medical staff has recommended be terminated. Two internists have been appointed to the peer-review committee; one has an office-based practice, and the other is a cardiologist. Neither is a hospitalist.

I am trying to convince the medical staff that there should be a hospitalist on the peer-review committee because I believe what a hospitalist does each day is fundamentally different in scope and patient mix than the other two internists. My argument will be much stronger if it is the case that a hospitalist’s practice is now its own medical specialty.

Can you point me to any information or articles that support my belief that hospital practice is now a separate specialty?

Anxious Attorney

Dr. Hospitalist responds: Is a hospitalist practice sufficiently different than that of an office-based internist or cardiologist, so much so that peer-review activities would necessitate at a minimum some involvement of other hospitalists? To answer this question, I think we need to understand the definition of a hospitalist.

I recently heard a doctor describe himself as a hospitalist despite working clinically in the hospital only one month annually. Is he correct in defining himself as a hospitalist? If so, how would we distinguish him from primary care doctors who spend one-twelfth of their work life caring for hospitalized patients?

SHM defines hospitalists as “physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.” Based on this definition, the doctor who spends one month annually caring for inpatients could be a hospitalist if the remainder of his work involved teaching, research, and leadership related to hospital medicine.

In your example, you cite two physicians on the peer-review committee: an office based internist and a cardiologist. Is it reasonable to consider their work similar to or different from that of a hospitalist? In the case of the internist, I think the key point is the fact you described him as office-based. That suggests to me his primary professional focus does not involve hospitalized patients.

One could argue that since both the hospitalist and the office-based internist were trained in internal medicine and both have American Board of Internal Medicine certification, they should be considered peers. I would point out that one’s specialty training has nothing to do with the definition of a hospitalist.

Although the majority of hospitalists in this country are internists, many others are family physicians and pediatricians. Some have subspecialty training, some don’t. Even obstetricians and surgeons are defining themselves as hospitalists.

With all that in mind, would we consider the cardiologist a hospitalist? Again, I think it would depend on the nature of the cardiologist practice. If this cardiologist has a primarily outpatient practice, that would be quite different from a hospitalist practice.

What if this cardiologist’s practice primarily is inpatient? I think it is reasonable to think about the scope of these physicians’ practices. Assuming the cardiologist practice is limited to the care of patients with primary cardiac issues, this would be a much narrower scope than that of most hospitalists.

It also is important to consider the training of the hospitalist. Take geriatrics hospitalists, for instance. The scope of their practice may be quite similar to that of a geriatrician who spends the majority of time caring for hospitalized patients.

Does the hospitalist have additional cardiology training? Does the focus of discussion at peer-review committee involve care of patients with primarily cardiac needs? The issue of which physicians should serve on peer-review committees when evaluating hospitalists is a complicated one that demands further scrutiny. TH

Maternity Maneuvers

How do most hospitalist groups manage maternity leave? I recently took six weeks for maternity leave. My colleagues worked my shifts, and I have virtually paid them all back. To do so I often would end up working 18 to 20 days consecutively and numerous weekends. This was not ideal on many levels. I most likely will not [receive a] bonus this year as well. Is there a better way?

New Mom in Midwest

Dr. Hospitalist responds: Congratulations on the birth of your child. As you recognize, becoming a parent is a wonderful experience but also can be stressful. It is not easy to balance the competing demands of family and work.

Medical leave is not unique to hospitalists—but with the average age of hospitalists being 37, it is commonplace to have hospitalist staff start families at this stage of their lives. In fact, as a hospitalist director, it would be foolish for me not to expect and plan for maternity and paternity leaves.

Medical leaves often are stressful for hospitalist programs because of the need to find replacement staff to fill the work schedule. There is no “best” way to cover the schedule during medical leaves. One thing is certain: Not offering medical leave is not only unrealistic, it may be against the law.

Hospitalist directors and those contemplating medical leave from work should familiarize themselves with the federal government’s Family Medical Leave Act (FMLA). Of course, I’m not an attorney; anyone who is looking for accurate advice concerning FMLA and other legal matters should consult a lawyer.

Briefly stated, the FMLA requires that “covered employers must grant an eligible employee up to a total of 12 work weeks of unpaid leave during any 12-month period for one or more of the following reasons:

• Birth and care of the newborn child of the employee;
• Placement with the employee of a son or daughter for adoption or foster care;
• To care for an immediate family member (spouse, child, or parent) with a serious health condition; or
• To take medical leave when the employee is unable to work because of a serious health condition.

It is important to know that the FMLA strictly defines eligibility criteria. For example, a covered employer is one who “employs 50 or more employees for each working day during each of 20 or more calendar work weeks in the current or preceding calendar year.” There also are strict criteria that define whether one is an eligible employee. It is important to note that FMLA does not guarantee paid time off—it only requires unpaid leave. You can find additional information about the FMLA online at the government’s Web site: www.dol.gov/esa/whd/fmla.

Peer Pressure

I am an attorney who often represents physicians in hospital peer-review matters. I represent a hospitalist whom the medical staff has recommended be terminated. Two internists have been appointed to the peer-review committee; one has an office-based practice, and the other is a cardiologist. Neither is a hospitalist.

I am trying to convince the medical staff that there should be a hospitalist on the peer-review committee because I believe what a hospitalist does each day is fundamentally different in scope and patient mix than the other two internists. My argument will be much stronger if it is the case that a hospitalist’s practice is now its own medical specialty.

Can you point me to any information or articles that support my belief that hospital practice is now a separate specialty?

Anxious Attorney

Dr. Hospitalist responds: Is a hospitalist practice sufficiently different than that of an office-based internist or cardiologist, so much so that peer-review activities would necessitate at a minimum some involvement of other hospitalists? To answer this question, I think we need to understand the definition of a hospitalist.

I recently heard a doctor describe himself as a hospitalist despite working clinically in the hospital only one month annually. Is he correct in defining himself as a hospitalist? If so, how would we distinguish him from primary care doctors who spend one-twelfth of their work life caring for hospitalized patients?

SHM defines hospitalists as “physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.” Based on this definition, the doctor who spends one month annually caring for inpatients could be a hospitalist if the remainder of his work involved teaching, research, and leadership related to hospital medicine.

In your example, you cite two physicians on the peer-review committee: an office based internist and a cardiologist. Is it reasonable to consider their work similar to or different from that of a hospitalist? In the case of the internist, I think the key point is the fact you described him as office-based. That suggests to me his primary professional focus does not involve hospitalized patients.

One could argue that since both the hospitalist and the office-based internist were trained in internal medicine and both have American Board of Internal Medicine certification, they should be considered peers. I would point out that one’s specialty training has nothing to do with the definition of a hospitalist.

Although the majority of hospitalists in this country are internists, many others are family physicians and pediatricians. Some have subspecialty training, some don’t. Even obstetricians and surgeons are defining themselves as hospitalists.

With all that in mind, would we consider the cardiologist a hospitalist? Again, I think it would depend on the nature of the cardiologist practice. If this cardiologist has a primarily outpatient practice, that would be quite different from a hospitalist practice.

What if this cardiologist’s practice primarily is inpatient? I think it is reasonable to think about the scope of these physicians’ practices. Assuming the cardiologist practice is limited to the care of patients with primary cardiac issues, this would be a much narrower scope than that of most hospitalists.

It also is important to consider the training of the hospitalist. Take geriatrics hospitalists, for instance. The scope of their practice may be quite similar to that of a geriatrician who spends the majority of time caring for hospitalized patients.

Does the hospitalist have additional cardiology training? Does the focus of discussion at peer-review committee involve care of patients with primarily cardiac needs? The issue of which physicians should serve on peer-review committees when evaluating hospitalists is a complicated one that demands further scrutiny. TH

Clinical Privileges

Question: Is there a standard percentage of time for inpatient care that is used to define a hospitalist? (i.e., 25% of time in inpatient activities = expert in hospital medicine). Our hospitalist section is drafting a clinical privilege form, and I have been searching for a national standard.

Heather Toth, MD, Hospital Medicine, Department of Pediatrics, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee

Dr. Hospitalist responds: You and others may be aware of a little secret in hospital medicine: hospitalists have been around in this country for decades.

Even though Drs. Robert Wachter and Lee Goldman coined the term “hospitalist” in the New England Journal of Medicine in 1996, hospitalists have been working our nation’s hospitals for a long, long time.

Don’t get me wrong—I am not diminishing their roles in establishing the field of hospital medicine. What I am saying is that hospitalists were around before 1996, but nobody had defined their role. and nobody knew what to call them.

Drs. Wachter and Goldman did not only name the profession, they also gave it credibility. Prior to the mid-’90s, I get the sense most medical professionals viewed hospitalists as second-rate doctors. These hospital doctors were doing the jobs most respectable doctors didn’t want to do or didn’t have to do.

Those jobs included caring for critically ill patients when other doctors were unavailable or didn’t have the time to see their patients. This could be at 2 p.m. or 2 a.m. in most hospitals. Drs. Wachter and Goldman were, and are, respected academic physicians. In their seminal article, they essentially called out these hospital doctors and lauded their roles in the hospital. Moreover, they anticipated growth in this field of medicine. In some ways, they were saying, “I’m OK and you’re OK. It’s OK to be a hospitalist.”

Well, the rest is history; whereas we had about 2,000 hospitalists in the mid-’90s, we now have an estimated 20,000 hospitalists in the country.

It seems nowadays, many doctors are calling themselves hospitalists. How many times have you heard a doctor say, “I was a hospitalist before the field existed?” I wonder whether we really had so many hospital doctors back then.

Or, is it an issue of how one defines “hospitalist”? Some doctors may be making claims about being a hospitalist because it is now acceptable to be a hospitalist. Whereas 15 years ago, hospitalists were looking in at the establishment; in some parts of the country, hospitalists have become the establishment.

My brother was a member of his high school basketball team, which was ranked No. 1 in the state. Ignore the fact that as a scrub he never came close to stepping onto the court during a game. He still made sure people knew he was a player on the championship team. Everyone wants to be part of a winner.

There may be other reasons to call oneself a hospitalist. Many view hospitalists as specialists in inpatient care. Before long, hospitals may grant privileges to hospitalists that they may not grant to other types of doctors. We have seen this before.

At one time, there was virtually no such thing as a “closed” ICU in hospitals.

Evidence suggested patients received better care when intensivists cared for ICU patients. Today, it is rare to find an academic medical center without a closed ICU, and many community hospitals have adopted a similar model.

Whether doctors are calling themselves “hospitalists” because it is the cool thing to do now or whether it is a matter of turf, you bring up a good question: “How much inpatient work does one have to do to be called a hospitalist?” Drs. Wachter and Goldman certainly didn’t specifically address this issue in their article, and neither has SHM.

SHM’s definition of a hospitalist is: “Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.”

This definition of a hospitalist is about as good as any I have heard. It should be noted this definition makes no mention of training. One can be an internist, family physician, pediatrician, obstetrician, or general surgeon and be a hospitalist.

With this definition, it does mean, however, you can take care of patients one to two months out of the year and still be considered a “hospitalist” as long as your non-clinical work (teaching, research, and leadership roles) is related to hospital medicine.

I will caution you however as you draft your clinical privilege form that whether you are a hospitalist or not is a different issue than whether you are qualified or not to provide a specific type of clinical care.

Hospitalists are individuals with different knowledge bases and skills sets. You can work clinically as a hospitalist 12 months a year, but if you have never put in a central line, your hospital should not grant you privileges to put in central lines until you have demonstrated some minimal level of competency.

I suspect you are not alone. There are many doctors and institutions around the country that are or will be struggling with the same issues you are facing. TH

Clinical Privileges

Question: Is there a standard percentage of time for inpatient care that is used to define a hospitalist? (i.e., 25% of time in inpatient activities = expert in hospital medicine). Our hospitalist section is drafting a clinical privilege form, and I have been searching for a national standard.

Heather Toth, MD, Hospital Medicine, Department of Pediatrics, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee

Dr. Hospitalist responds: You and others may be aware of a little secret in hospital medicine: hospitalists have been around in this country for decades.

Even though Drs. Robert Wachter and Lee Goldman coined the term “hospitalist” in the New England Journal of Medicine in 1996, hospitalists have been working our nation’s hospitals for a long, long time.

Don’t get me wrong—I am not diminishing their roles in establishing the field of hospital medicine. What I am saying is that hospitalists were around before 1996, but nobody had defined their role. and nobody knew what to call them.

Drs. Wachter and Goldman did not only name the profession, they also gave it credibility. Prior to the mid-’90s, I get the sense most medical professionals viewed hospitalists as second-rate doctors. These hospital doctors were doing the jobs most respectable doctors didn’t want to do or didn’t have to do.

Those jobs included caring for critically ill patients when other doctors were unavailable or didn’t have the time to see their patients. This could be at 2 p.m. or 2 a.m. in most hospitals. Drs. Wachter and Goldman were, and are, respected academic physicians. In their seminal article, they essentially called out these hospital doctors and lauded their roles in the hospital. Moreover, they anticipated growth in this field of medicine. In some ways, they were saying, “I’m OK and you’re OK. It’s OK to be a hospitalist.”

Well, the rest is history; whereas we had about 2,000 hospitalists in the mid-’90s, we now have an estimated 20,000 hospitalists in the country.

It seems nowadays, many doctors are calling themselves hospitalists. How many times have you heard a doctor say, “I was a hospitalist before the field existed?” I wonder whether we really had so many hospital doctors back then.

Or, is it an issue of how one defines “hospitalist”? Some doctors may be making claims about being a hospitalist because it is now acceptable to be a hospitalist. Whereas 15 years ago, hospitalists were looking in at the establishment; in some parts of the country, hospitalists have become the establishment.

My brother was a member of his high school basketball team, which was ranked No. 1 in the state. Ignore the fact that as a scrub he never came close to stepping onto the court during a game. He still made sure people knew he was a player on the championship team. Everyone wants to be part of a winner.

There may be other reasons to call oneself a hospitalist. Many view hospitalists as specialists in inpatient care. Before long, hospitals may grant privileges to hospitalists that they may not grant to other types of doctors. We have seen this before.

At one time, there was virtually no such thing as a “closed” ICU in hospitals.

Evidence suggested patients received better care when intensivists cared for ICU patients. Today, it is rare to find an academic medical center without a closed ICU, and many community hospitals have adopted a similar model.

Whether doctors are calling themselves “hospitalists” because it is the cool thing to do now or whether it is a matter of turf, you bring up a good question: “How much inpatient work does one have to do to be called a hospitalist?” Drs. Wachter and Goldman certainly didn’t specifically address this issue in their article, and neither has SHM.

SHM’s definition of a hospitalist is: “Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.”

This definition of a hospitalist is about as good as any I have heard. It should be noted this definition makes no mention of training. One can be an internist, family physician, pediatrician, obstetrician, or general surgeon and be a hospitalist.

With this definition, it does mean, however, you can take care of patients one to two months out of the year and still be considered a “hospitalist” as long as your non-clinical work (teaching, research, and leadership roles) is related to hospital medicine.

I will caution you however as you draft your clinical privilege form that whether you are a hospitalist or not is a different issue than whether you are qualified or not to provide a specific type of clinical care.

Hospitalists are individuals with different knowledge bases and skills sets. You can work clinically as a hospitalist 12 months a year, but if you have never put in a central line, your hospital should not grant you privileges to put in central lines until you have demonstrated some minimal level of competency.

I suspect you are not alone. There are many doctors and institutions around the country that are or will be struggling with the same issues you are facing. TH

Clinical Privileges

Question: Is there a standard percentage of time for inpatient care that is used to define a hospitalist? (i.e., 25% of time in inpatient activities = expert in hospital medicine). Our hospitalist section is drafting a clinical privilege form, and I have been searching for a national standard.

Heather Toth, MD, Hospital Medicine, Department of Pediatrics, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee

Dr. Hospitalist responds: You and others may be aware of a little secret in hospital medicine: hospitalists have been around in this country for decades.

Even though Drs. Robert Wachter and Lee Goldman coined the term “hospitalist” in the New England Journal of Medicine in 1996, hospitalists have been working our nation’s hospitals for a long, long time.

Don’t get me wrong—I am not diminishing their roles in establishing the field of hospital medicine. What I am saying is that hospitalists were around before 1996, but nobody had defined their role. and nobody knew what to call them.

Drs. Wachter and Goldman did not only name the profession, they also gave it credibility. Prior to the mid-’90s, I get the sense most medical professionals viewed hospitalists as second-rate doctors. These hospital doctors were doing the jobs most respectable doctors didn’t want to do or didn’t have to do.

Those jobs included caring for critically ill patients when other doctors were unavailable or didn’t have the time to see their patients. This could be at 2 p.m. or 2 a.m. in most hospitals. Drs. Wachter and Goldman were, and are, respected academic physicians. In their seminal article, they essentially called out these hospital doctors and lauded their roles in the hospital. Moreover, they anticipated growth in this field of medicine. In some ways, they were saying, “I’m OK and you’re OK. It’s OK to be a hospitalist.”

Well, the rest is history; whereas we had about 2,000 hospitalists in the mid-’90s, we now have an estimated 20,000 hospitalists in the country.

It seems nowadays, many doctors are calling themselves hospitalists. How many times have you heard a doctor say, “I was a hospitalist before the field existed?” I wonder whether we really had so many hospital doctors back then.

Or, is it an issue of how one defines “hospitalist”? Some doctors may be making claims about being a hospitalist because it is now acceptable to be a hospitalist. Whereas 15 years ago, hospitalists were looking in at the establishment; in some parts of the country, hospitalists have become the establishment.

My brother was a member of his high school basketball team, which was ranked No. 1 in the state. Ignore the fact that as a scrub he never came close to stepping onto the court during a game. He still made sure people knew he was a player on the championship team. Everyone wants to be part of a winner.

There may be other reasons to call oneself a hospitalist. Many view hospitalists as specialists in inpatient care. Before long, hospitals may grant privileges to hospitalists that they may not grant to other types of doctors. We have seen this before.

At one time, there was virtually no such thing as a “closed” ICU in hospitals.

Evidence suggested patients received better care when intensivists cared for ICU patients. Today, it is rare to find an academic medical center without a closed ICU, and many community hospitals have adopted a similar model.

Whether doctors are calling themselves “hospitalists” because it is the cool thing to do now or whether it is a matter of turf, you bring up a good question: “How much inpatient work does one have to do to be called a hospitalist?” Drs. Wachter and Goldman certainly didn’t specifically address this issue in their article, and neither has SHM.

SHM’s definition of a hospitalist is: “Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.”

This definition of a hospitalist is about as good as any I have heard. It should be noted this definition makes no mention of training. One can be an internist, family physician, pediatrician, obstetrician, or general surgeon and be a hospitalist.

With this definition, it does mean, however, you can take care of patients one to two months out of the year and still be considered a “hospitalist” as long as your non-clinical work (teaching, research, and leadership roles) is related to hospital medicine.

I will caution you however as you draft your clinical privilege form that whether you are a hospitalist or not is a different issue than whether you are qualified or not to provide a specific type of clinical care.

Hospitalists are individuals with different knowledge bases and skills sets. You can work clinically as a hospitalist 12 months a year, but if you have never put in a central line, your hospital should not grant you privileges to put in central lines until you have demonstrated some minimal level of competency.

I suspect you are not alone. There are many doctors and institutions around the country that are or will be struggling with the same issues you are facing. TH

Consult for an HMG

Question: We are an established hospitalist group going on two years. We started with two full-time physicians and now have five. We obviously have room for improvement and growth. Are there any hospitalist physician consultants who would be able to spend a couple of days with us to evaluate our program and review our systems?

Montell Hutchison,

Business Development Specialist,

Marietta Memorial Hospital,

Marietta, Ohio

Dr. Hospitalist responds: Since the term hospitalist was coined in 1996, the field has grown rapidly. The majority of hospitalist programs are less than five years old. Many hospitalist programs, having grown rapidly over the past few years, are planning to evaluate and improve their performance.

There are a number of options available to help programs benchmark themselves to industry standards. Hiring a consultant is certainly a reasonable choice. SHM has been a particularly valuable resource to help leaders understand how to evaluate their program.

On the Practice Resource section of its Web site (www.hospitalmedicine.org), SHM provides the names and descriptions of several practice management consultants. Also on the site is the downloadable dashboard white paper “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards,” developed by the SHM Benchmarks Committee.

The white paper discusses “issues related to developing, reporting and interpreting performance data.” SHM has also developed the practice management course “Best Practices in Managing a Hospital Medicine Program” and published the book Hospitalists: A Guide to Building and Sustaining a Successful Career to assist those interested in evaluating and improving their hospitalist program.

Lastly, SHM surveys hospitalists every other year to gather productivity and compensation date. The results of the latest “Bi-Annual Survey on the State of the Hospital Medicine Movement” will be released at the SHM Annual Meeting in San Diego April 3-5. Survey information will be available on its Web site shortly thereafter.

Lend A Hand

Question: I am a certified diabetes educator with 20 years’ experience in diabetes. I’m about to graduate as an adult nurse practitioner (ANP). My goal is to work with management of inpatient diabetes. Are you aware of any models of ANPs working for or with hospitalists?

Potential Team Member, Ohio

Dr. Hospitalist responds: There are about 20,000 hospitalists in the country. SHM believes that number could grow to 40,000. I am not surprised by the size of that estimate. Just about every hospital I know wants to develop or expand its hospitalist program.

Hospital medicine has filled its ranks over the past decade largely at the expense of primary care. Many physicians have left primary care for hospital medicine. At the same time, many graduates of internal medicine and family medicine training programs have chosen employment in hospital medicine instead of outpatient medicine.

Despite this trend, we are still short of hospitalists. The long-term solution is to expand the numbers of trainees who choose hospital medicine as a career. We are unlikely to see that occur rapidly over the short term. Another potential solution is to increase hospitalist efficiency.

Many in the field are working to redesign systems in the hospital to increase hospitalist efficiency and productivity. Again, these efforts will take time. Adding non-physician providers as care extenders is another viable option many programs are exploring. The results of the latest SHM productivity and compensation survey “Bi-Annual Survey on the State of the Hospital Medicine Movement” being released in April will give a sense of how many midlevel providers (nurse practitioners and physicians’ assistants) are working in hospitalist programs. It will not, however, fully describe their roles and responsibilities. I suspect more hospitalist programs are employing midlevel providers, but the majority of programs do not have midlevel providers among their staff.

For hospitalist programs entertaining the notion of hiring a midlevel provider (and for those midlevel providers interested in joining a hospitalist program), there are barriers to such a relationship. One inherent problem is that most hospitalists do not understand how to work with midlevel providers. Many hospitalists are unaware of the midlevel providers’ education and training.

I am not surprised. Most hospitalists did not work with midlevel providers during their training. There are not only differences in education and training among nurse practitioners (NPs) and physicians’ assistants (PAs), but many state licensing boards also limit their scopes of practice in a different manner. I find that many hospitalists want their midlevel providers to do the scut work hospitalists don’t want to do or feel they don’t have time to do.

I feel this is an expensive way to hire someone to do discharge summaries, put in orders, and make follow-up appointments. One does not need a midlevel education and training to perform those tasks. I suspect most midlevel providers—like hospitalists—find these tasks unsatisfying if it is the majority of their job description. Hospitalist programs would be better served if they involved midlevel providers in the care of patients. But this will require additional training to help hospitalist understand the level of supervision that is necessary for midlevel providers.

For hospitalists who work with midlevel providers, I find too often that many provide too much or too little supervision. Neither is appropriate. Another barrier in some parts of the country relates to the compensation of hospitalists and midlevel providers.

In the Northeast and on the West Coast, for example, we find smaller differences between hospitalist and NP salaries. Since NPs bill at 85% of physician billing, it may not necessarily make financial sense to hire NPs when one can hire a physician at slightly higher cost.

I hope I have not dissuaded you from pursuing a job in hospital medicine. I believe the development of roles for midlevel providers in hospital medicine is critical to the continued expansion of hospital medicine in this country.

I implore hospitalists and midlevel providers to work together to explore and establish models of care that will provide sustainable career opportunities for midlevel providers in hospital medicine. TH

Consult for an HMG

Question: We are an established hospitalist group going on two years. We started with two full-time physicians and now have five. We obviously have room for improvement and growth. Are there any hospitalist physician consultants who would be able to spend a couple of days with us to evaluate our program and review our systems?

Montell Hutchison,

Business Development Specialist,

Marietta Memorial Hospital,

Marietta, Ohio

Dr. Hospitalist responds: Since the term hospitalist was coined in 1996, the field has grown rapidly. The majority of hospitalist programs are less than five years old. Many hospitalist programs, having grown rapidly over the past few years, are planning to evaluate and improve their performance.

There are a number of options available to help programs benchmark themselves to industry standards. Hiring a consultant is certainly a reasonable choice. SHM has been a particularly valuable resource to help leaders understand how to evaluate their program.

On the Practice Resource section of its Web site (www.hospitalmedicine.org), SHM provides the names and descriptions of several practice management consultants. Also on the site is the downloadable dashboard white paper “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards,” developed by the SHM Benchmarks Committee.

The white paper discusses “issues related to developing, reporting and interpreting performance data.” SHM has also developed the practice management course “Best Practices in Managing a Hospital Medicine Program” and published the book Hospitalists: A Guide to Building and Sustaining a Successful Career to assist those interested in evaluating and improving their hospitalist program.

Lastly, SHM surveys hospitalists every other year to gather productivity and compensation date. The results of the latest “Bi-Annual Survey on the State of the Hospital Medicine Movement” will be released at the SHM Annual Meeting in San Diego April 3-5. Survey information will be available on its Web site shortly thereafter.

Lend A Hand

Question: I am a certified diabetes educator with 20 years’ experience in diabetes. I’m about to graduate as an adult nurse practitioner (ANP). My goal is to work with management of inpatient diabetes. Are you aware of any models of ANPs working for or with hospitalists?

Potential Team Member, Ohio

Dr. Hospitalist responds: There are about 20,000 hospitalists in the country. SHM believes that number could grow to 40,000. I am not surprised by the size of that estimate. Just about every hospital I know wants to develop or expand its hospitalist program.

Hospital medicine has filled its ranks over the past decade largely at the expense of primary care. Many physicians have left primary care for hospital medicine. At the same time, many graduates of internal medicine and family medicine training programs have chosen employment in hospital medicine instead of outpatient medicine.

Despite this trend, we are still short of hospitalists. The long-term solution is to expand the numbers of trainees who choose hospital medicine as a career. We are unlikely to see that occur rapidly over the short term. Another potential solution is to increase hospitalist efficiency.

Many in the field are working to redesign systems in the hospital to increase hospitalist efficiency and productivity. Again, these efforts will take time. Adding non-physician providers as care extenders is another viable option many programs are exploring. The results of the latest SHM productivity and compensation survey “Bi-Annual Survey on the State of the Hospital Medicine Movement” being released in April will give a sense of how many midlevel providers (nurse practitioners and physicians’ assistants) are working in hospitalist programs. It will not, however, fully describe their roles and responsibilities. I suspect more hospitalist programs are employing midlevel providers, but the majority of programs do not have midlevel providers among their staff.

For hospitalist programs entertaining the notion of hiring a midlevel provider (and for those midlevel providers interested in joining a hospitalist program), there are barriers to such a relationship. One inherent problem is that most hospitalists do not understand how to work with midlevel providers. Many hospitalists are unaware of the midlevel providers’ education and training.

I am not surprised. Most hospitalists did not work with midlevel providers during their training. There are not only differences in education and training among nurse practitioners (NPs) and physicians’ assistants (PAs), but many state licensing boards also limit their scopes of practice in a different manner. I find that many hospitalists want their midlevel providers to do the scut work hospitalists don’t want to do or feel they don’t have time to do.

I feel this is an expensive way to hire someone to do discharge summaries, put in orders, and make follow-up appointments. One does not need a midlevel education and training to perform those tasks. I suspect most midlevel providers—like hospitalists—find these tasks unsatisfying if it is the majority of their job description. Hospitalist programs would be better served if they involved midlevel providers in the care of patients. But this will require additional training to help hospitalist understand the level of supervision that is necessary for midlevel providers.

For hospitalists who work with midlevel providers, I find too often that many provide too much or too little supervision. Neither is appropriate. Another barrier in some parts of the country relates to the compensation of hospitalists and midlevel providers.

In the Northeast and on the West Coast, for example, we find smaller differences between hospitalist and NP salaries. Since NPs bill at 85% of physician billing, it may not necessarily make financial sense to hire NPs when one can hire a physician at slightly higher cost.

I hope I have not dissuaded you from pursuing a job in hospital medicine. I believe the development of roles for midlevel providers in hospital medicine is critical to the continued expansion of hospital medicine in this country.

I implore hospitalists and midlevel providers to work together to explore and establish models of care that will provide sustainable career opportunities for midlevel providers in hospital medicine. TH

Consult for an HMG

Question: We are an established hospitalist group going on two years. We started with two full-time physicians and now have five. We obviously have room for improvement and growth. Are there any hospitalist physician consultants who would be able to spend a couple of days with us to evaluate our program and review our systems?

Montell Hutchison,

Business Development Specialist,

Marietta Memorial Hospital,

Marietta, Ohio

Dr. Hospitalist responds: Since the term hospitalist was coined in 1996, the field has grown rapidly. The majority of hospitalist programs are less than five years old. Many hospitalist programs, having grown rapidly over the past few years, are planning to evaluate and improve their performance.

There are a number of options available to help programs benchmark themselves to industry standards. Hiring a consultant is certainly a reasonable choice. SHM has been a particularly valuable resource to help leaders understand how to evaluate their program.

On the Practice Resource section of its Web site (www.hospitalmedicine.org), SHM provides the names and descriptions of several practice management consultants. Also on the site is the downloadable dashboard white paper “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards,” developed by the SHM Benchmarks Committee.

The white paper discusses “issues related to developing, reporting and interpreting performance data.” SHM has also developed the practice management course “Best Practices in Managing a Hospital Medicine Program” and published the book Hospitalists: A Guide to Building and Sustaining a Successful Career to assist those interested in evaluating and improving their hospitalist program.

Lastly, SHM surveys hospitalists every other year to gather productivity and compensation date. The results of the latest “Bi-Annual Survey on the State of the Hospital Medicine Movement” will be released at the SHM Annual Meeting in San Diego April 3-5. Survey information will be available on its Web site shortly thereafter.

Lend A Hand

Question: I am a certified diabetes educator with 20 years’ experience in diabetes. I’m about to graduate as an adult nurse practitioner (ANP). My goal is to work with management of inpatient diabetes. Are you aware of any models of ANPs working for or with hospitalists?

Potential Team Member, Ohio

Dr. Hospitalist responds: There are about 20,000 hospitalists in the country. SHM believes that number could grow to 40,000. I am not surprised by the size of that estimate. Just about every hospital I know wants to develop or expand its hospitalist program.

Hospital medicine has filled its ranks over the past decade largely at the expense of primary care. Many physicians have left primary care for hospital medicine. At the same time, many graduates of internal medicine and family medicine training programs have chosen employment in hospital medicine instead of outpatient medicine.

Despite this trend, we are still short of hospitalists. The long-term solution is to expand the numbers of trainees who choose hospital medicine as a career. We are unlikely to see that occur rapidly over the short term. Another potential solution is to increase hospitalist efficiency.

Many in the field are working to redesign systems in the hospital to increase hospitalist efficiency and productivity. Again, these efforts will take time. Adding non-physician providers as care extenders is another viable option many programs are exploring. The results of the latest SHM productivity and compensation survey “Bi-Annual Survey on the State of the Hospital Medicine Movement” being released in April will give a sense of how many midlevel providers (nurse practitioners and physicians’ assistants) are working in hospitalist programs. It will not, however, fully describe their roles and responsibilities. I suspect more hospitalist programs are employing midlevel providers, but the majority of programs do not have midlevel providers among their staff.

For hospitalist programs entertaining the notion of hiring a midlevel provider (and for those midlevel providers interested in joining a hospitalist program), there are barriers to such a relationship. One inherent problem is that most hospitalists do not understand how to work with midlevel providers. Many hospitalists are unaware of the midlevel providers’ education and training.

I am not surprised. Most hospitalists did not work with midlevel providers during their training. There are not only differences in education and training among nurse practitioners (NPs) and physicians’ assistants (PAs), but many state licensing boards also limit their scopes of practice in a different manner. I find that many hospitalists want their midlevel providers to do the scut work hospitalists don’t want to do or feel they don’t have time to do.

I feel this is an expensive way to hire someone to do discharge summaries, put in orders, and make follow-up appointments. One does not need a midlevel education and training to perform those tasks. I suspect most midlevel providers—like hospitalists—find these tasks unsatisfying if it is the majority of their job description. Hospitalist programs would be better served if they involved midlevel providers in the care of patients. But this will require additional training to help hospitalist understand the level of supervision that is necessary for midlevel providers.

For hospitalists who work with midlevel providers, I find too often that many provide too much or too little supervision. Neither is appropriate. Another barrier in some parts of the country relates to the compensation of hospitalists and midlevel providers.

In the Northeast and on the West Coast, for example, we find smaller differences between hospitalist and NP salaries. Since NPs bill at 85% of physician billing, it may not necessarily make financial sense to hire NPs when one can hire a physician at slightly higher cost.

I hope I have not dissuaded you from pursuing a job in hospital medicine. I believe the development of roles for midlevel providers in hospital medicine is critical to the continued expansion of hospital medicine in this country.

I implore hospitalists and midlevel providers to work together to explore and establish models of care that will provide sustainable career opportunities for midlevel providers in hospital medicine. TH