Jeff Glasheen, MD

Round One

“Plane down, mass casualties possible; initiate disaster plan.”

The page interrupted my evening out with friends a few Saturday nights ago. Looking up from my dinner, I noticed the restaurant television had cut away to a news story at Denver International Airport. Continental Flight 1404, en route to Houston, had crashed during takeoff, belly-flopping to a fiery rest a few hundred yards off the runway. The airport is about 10 miles from the nearest hospital—mine.

The situation ended considerably better than originally expected. Thirty-eight people were treated at several Denver hospitals, 11 of them at my hospital, with most patients discharged from the emergency department. No one died. The case remains under review, and little is known about the cause of the crash.

Round Two

“Give me a call. I need to talk to you urgently.”

That page arrived the following Monday morning. It was from a co-worker. There had been an unexpected bad outcome in a young male patient. The hospital’s quality and risk management group had found out about the case and called for a peer review. My colleague was scared; would he be publicly criticized? Punished? Fired?

The patient had been admitted with a chronic disease flare-up. He was on the mend after receiving an increased dose of medication. The night before he was scheduled to be discharged, he developed a new symptom, was evaluated by the cross-cover team, and a plan was set in motion. However, a critical lab result, which became available overnight, mistakenly was not called to the provider and went unnoticed by the primary team that triaged the patient to the end of the team’s rounds. By then, he was in extremis.

Getty Images

Planes and Patients

The proximity of these two events provoked comparisons.

By now, comparing healthcare to the aviation industry has become cliché. Both industries demand highly trained and skilled conductors; errors in both industries can result in death; both depend on technology; and both have turned to systems engineering to improve efficiencies and reduce mistakes. This is where the two industries diverge, and I think we get it wrong in medicine.

In aviation, there are very proscriptive algorithms that must be followed, and much of a pilot’s work is under constant scrutiny by air traffic controllers and data recorders. A deviation in protocol rarely goes unnoticed. Errors are systematically compiled, scrutinized, and compartmentalized, with the aim of further refining systems to reduce the likelihood of future errors. Although blame is often prescribed, it is in the context of improving the system. Thus, the aviation industry is awash with data to inform and fuel its systems engineering.

Meanwhile, in medicine our indelible sense of autonomy breeds variability, which is not only tolerated, but often goes unnoticed. Further, we employ a model of error analysis that focuses on affixing blame, as if somehow culpability will prevent future errors. Someone made an error, a bad outcome ensued, and the culprit must be identified and punished. This results in reprimand, remediation, or banishment from the medical staff. At times, this is an appropriate response, as some errors are so egregious or indicative of a chronic problem. More often, the punitive process misses the mark because it focuses on blame instead of prevention of the next error. Unlike the aviation industry, this leaves medicine bereft of data for improving our care systems.

“Blame and Punish” Doesn’t Work

There are two problems with the “blame and punish” approach. First, it is predicated on the belief that providers make errors because they are poorly trained, inept, or just plain careless. Sometimes this is the case.

However, the vast majority of peer reviews that I’ve participated in involved an error performed by extremely well trained, highly skilled clinicians with the highest level of integrity and vigilance. The real problem lies in the human condition.

Humans make mistakes. Always have, always will.

In college, I worked summers in a factory that applied coating to paper. This combined colossal machines spinning at breakneck speeds, huge rolls of paper, and hands—a recipe for handless employees. But accidents rarely happened. Over time, the mill engineers had designed systems so foolproof that the workers couldn’t chop their hands off, even if they wanted to. This level of safety was achieved, in principle, by learning how errors were made so that future errors could be prevented. It was not achieved by blaming handless employees. This paper-plant process recognizes the fallible nature of human beings; it’s the same recognition we need in medicine.

Whether we commit a systems error (e.g., the lab test results arrived after the patient was discharged), a cognitive error (e.g., I continue to believe this pulmonary embolism is pneumonia because my night-coverage partner signed it out as pneumonia), or simply a human error (e.g., the lab forgot to call a critical result to the ordering physician), we work in systems that often result in errors. And the only meaningful hope we have to reduce errors depends on our ability to identify them and build systems so safe that we couldn’t hurt a patient, even if we tried.

This leads to the second problem with the blame-and-punish mentality: It breeds concealment of errors, as providers become reticent to expose mistakes for fear of retribution. Thus, an important pipeline of information about system deficiencies dries up, and we are left to suffer the same cycle of errors.

Budging the quality and patient-safety needle will require a culture that freely and openly admits mistakes in order to analyze and prevent future mistakes. This is inherently difficult for most of us to do, and next to impossible when we fear reprimand. Then again, if we endeavor to fundamentally enhance the safety of hospital care, we must allow providers to openly discuss errors without fear of rebuke. Accomplishing this will require understanding, leadership and action—and it starts with each of us.

Anything short of this will just result in more bad pages. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of Hospital Medicine and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Round One

“Plane down, mass casualties possible; initiate disaster plan.”

The page interrupted my evening out with friends a few Saturday nights ago. Looking up from my dinner, I noticed the restaurant television had cut away to a news story at Denver International Airport. Continental Flight 1404, en route to Houston, had crashed during takeoff, belly-flopping to a fiery rest a few hundred yards off the runway. The airport is about 10 miles from the nearest hospital—mine.

The situation ended considerably better than originally expected. Thirty-eight people were treated at several Denver hospitals, 11 of them at my hospital, with most patients discharged from the emergency department. No one died. The case remains under review, and little is known about the cause of the crash.

Round Two

“Give me a call. I need to talk to you urgently.”

That page arrived the following Monday morning. It was from a co-worker. There had been an unexpected bad outcome in a young male patient. The hospital’s quality and risk management group had found out about the case and called for a peer review. My colleague was scared; would he be publicly criticized? Punished? Fired?

The patient had been admitted with a chronic disease flare-up. He was on the mend after receiving an increased dose of medication. The night before he was scheduled to be discharged, he developed a new symptom, was evaluated by the cross-cover team, and a plan was set in motion. However, a critical lab result, which became available overnight, mistakenly was not called to the provider and went unnoticed by the primary team that triaged the patient to the end of the team’s rounds. By then, he was in extremis.

Getty Images

Planes and Patients

The proximity of these two events provoked comparisons.

By now, comparing healthcare to the aviation industry has become cliché. Both industries demand highly trained and skilled conductors; errors in both industries can result in death; both depend on technology; and both have turned to systems engineering to improve efficiencies and reduce mistakes. This is where the two industries diverge, and I think we get it wrong in medicine.

In aviation, there are very proscriptive algorithms that must be followed, and much of a pilot’s work is under constant scrutiny by air traffic controllers and data recorders. A deviation in protocol rarely goes unnoticed. Errors are systematically compiled, scrutinized, and compartmentalized, with the aim of further refining systems to reduce the likelihood of future errors. Although blame is often prescribed, it is in the context of improving the system. Thus, the aviation industry is awash with data to inform and fuel its systems engineering.

Meanwhile, in medicine our indelible sense of autonomy breeds variability, which is not only tolerated, but often goes unnoticed. Further, we employ a model of error analysis that focuses on affixing blame, as if somehow culpability will prevent future errors. Someone made an error, a bad outcome ensued, and the culprit must be identified and punished. This results in reprimand, remediation, or banishment from the medical staff. At times, this is an appropriate response, as some errors are so egregious or indicative of a chronic problem. More often, the punitive process misses the mark because it focuses on blame instead of prevention of the next error. Unlike the aviation industry, this leaves medicine bereft of data for improving our care systems.

“Blame and Punish” Doesn’t Work

There are two problems with the “blame and punish” approach. First, it is predicated on the belief that providers make errors because they are poorly trained, inept, or just plain careless. Sometimes this is the case.

However, the vast majority of peer reviews that I’ve participated in involved an error performed by extremely well trained, highly skilled clinicians with the highest level of integrity and vigilance. The real problem lies in the human condition.

Humans make mistakes. Always have, always will.

In college, I worked summers in a factory that applied coating to paper. This combined colossal machines spinning at breakneck speeds, huge rolls of paper, and hands—a recipe for handless employees. But accidents rarely happened. Over time, the mill engineers had designed systems so foolproof that the workers couldn’t chop their hands off, even if they wanted to. This level of safety was achieved, in principle, by learning how errors were made so that future errors could be prevented. It was not achieved by blaming handless employees. This paper-plant process recognizes the fallible nature of human beings; it’s the same recognition we need in medicine.

Whether we commit a systems error (e.g., the lab test results arrived after the patient was discharged), a cognitive error (e.g., I continue to believe this pulmonary embolism is pneumonia because my night-coverage partner signed it out as pneumonia), or simply a human error (e.g., the lab forgot to call a critical result to the ordering physician), we work in systems that often result in errors. And the only meaningful hope we have to reduce errors depends on our ability to identify them and build systems so safe that we couldn’t hurt a patient, even if we tried.

This leads to the second problem with the blame-and-punish mentality: It breeds concealment of errors, as providers become reticent to expose mistakes for fear of retribution. Thus, an important pipeline of information about system deficiencies dries up, and we are left to suffer the same cycle of errors.

Budging the quality and patient-safety needle will require a culture that freely and openly admits mistakes in order to analyze and prevent future mistakes. This is inherently difficult for most of us to do, and next to impossible when we fear reprimand. Then again, if we endeavor to fundamentally enhance the safety of hospital care, we must allow providers to openly discuss errors without fear of rebuke. Accomplishing this will require understanding, leadership and action—and it starts with each of us.

Anything short of this will just result in more bad pages. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of Hospital Medicine and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Round One

“Plane down, mass casualties possible; initiate disaster plan.”

The page interrupted my evening out with friends a few Saturday nights ago. Looking up from my dinner, I noticed the restaurant television had cut away to a news story at Denver International Airport. Continental Flight 1404, en route to Houston, had crashed during takeoff, belly-flopping to a fiery rest a few hundred yards off the runway. The airport is about 10 miles from the nearest hospital—mine.

The situation ended considerably better than originally expected. Thirty-eight people were treated at several Denver hospitals, 11 of them at my hospital, with most patients discharged from the emergency department. No one died. The case remains under review, and little is known about the cause of the crash.

Round Two

“Give me a call. I need to talk to you urgently.”

That page arrived the following Monday morning. It was from a co-worker. There had been an unexpected bad outcome in a young male patient. The hospital’s quality and risk management group had found out about the case and called for a peer review. My colleague was scared; would he be publicly criticized? Punished? Fired?

The patient had been admitted with a chronic disease flare-up. He was on the mend after receiving an increased dose of medication. The night before he was scheduled to be discharged, he developed a new symptom, was evaluated by the cross-cover team, and a plan was set in motion. However, a critical lab result, which became available overnight, mistakenly was not called to the provider and went unnoticed by the primary team that triaged the patient to the end of the team’s rounds. By then, he was in extremis.

Getty Images

Planes and Patients

The proximity of these two events provoked comparisons.

By now, comparing healthcare to the aviation industry has become cliché. Both industries demand highly trained and skilled conductors; errors in both industries can result in death; both depend on technology; and both have turned to systems engineering to improve efficiencies and reduce mistakes. This is where the two industries diverge, and I think we get it wrong in medicine.

In aviation, there are very proscriptive algorithms that must be followed, and much of a pilot’s work is under constant scrutiny by air traffic controllers and data recorders. A deviation in protocol rarely goes unnoticed. Errors are systematically compiled, scrutinized, and compartmentalized, with the aim of further refining systems to reduce the likelihood of future errors. Although blame is often prescribed, it is in the context of improving the system. Thus, the aviation industry is awash with data to inform and fuel its systems engineering.

Meanwhile, in medicine our indelible sense of autonomy breeds variability, which is not only tolerated, but often goes unnoticed. Further, we employ a model of error analysis that focuses on affixing blame, as if somehow culpability will prevent future errors. Someone made an error, a bad outcome ensued, and the culprit must be identified and punished. This results in reprimand, remediation, or banishment from the medical staff. At times, this is an appropriate response, as some errors are so egregious or indicative of a chronic problem. More often, the punitive process misses the mark because it focuses on blame instead of prevention of the next error. Unlike the aviation industry, this leaves medicine bereft of data for improving our care systems.

“Blame and Punish” Doesn’t Work

There are two problems with the “blame and punish” approach. First, it is predicated on the belief that providers make errors because they are poorly trained, inept, or just plain careless. Sometimes this is the case.

However, the vast majority of peer reviews that I’ve participated in involved an error performed by extremely well trained, highly skilled clinicians with the highest level of integrity and vigilance. The real problem lies in the human condition.

Humans make mistakes. Always have, always will.

In college, I worked summers in a factory that applied coating to paper. This combined colossal machines spinning at breakneck speeds, huge rolls of paper, and hands—a recipe for handless employees. But accidents rarely happened. Over time, the mill engineers had designed systems so foolproof that the workers couldn’t chop their hands off, even if they wanted to. This level of safety was achieved, in principle, by learning how errors were made so that future errors could be prevented. It was not achieved by blaming handless employees. This paper-plant process recognizes the fallible nature of human beings; it’s the same recognition we need in medicine.

Whether we commit a systems error (e.g., the lab test results arrived after the patient was discharged), a cognitive error (e.g., I continue to believe this pulmonary embolism is pneumonia because my night-coverage partner signed it out as pneumonia), or simply a human error (e.g., the lab forgot to call a critical result to the ordering physician), we work in systems that often result in errors. And the only meaningful hope we have to reduce errors depends on our ability to identify them and build systems so safe that we couldn’t hurt a patient, even if we tried.

This leads to the second problem with the blame-and-punish mentality: It breeds concealment of errors, as providers become reticent to expose mistakes for fear of retribution. Thus, an important pipeline of information about system deficiencies dries up, and we are left to suffer the same cycle of errors.

Budging the quality and patient-safety needle will require a culture that freely and openly admits mistakes in order to analyze and prevent future mistakes. This is inherently difficult for most of us to do, and next to impossible when we fear reprimand. Then again, if we endeavor to fundamentally enhance the safety of hospital care, we must allow providers to openly discuss errors without fear of rebuke. Accomplishing this will require understanding, leadership and action—and it starts with each of us.

Anything short of this will just result in more bad pages. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of Hospital Medicine and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

How often are patients in your program readmitted in 30 days to any hospital? I know many of you monitor readmission rates back to your own program or facility. But if you examine the patient perspective, how often are patients you discharge being readmitted to any acute care hospital within 30 days?

Given the increasing frequency that the Centers for Medicare and Medicaid Services (CMS) is reporting about readmission rates, I asked my quality director to research our hospital’s data.

As would any reasonable chief medical officer (CMO), I figured we probably had some opportunities for improvement, but overall I felt the numbers were probably fine. Like any hospital I have worked in, we have a core group of patients who return to the hospital frequently. But from a working hospitalist perspective, it didn’t seem to be a problem in our hospital.

So, when the data returned, our initial impressions about the rates were reaffirmed. The overall hospital 30-day readmit rate to our hospital was about 6%. We looked across different payers, socioeconomic groups, discharging services, and diagnosis for areas of opportunity. We found that two populations had slightly higher rates of readmission—congestive heart failure (CHF) and sickle-cell pain crisis—but in general, there were no particular outliers.

I commissioned two quality improvement groups to begin looking at these areas, though I felt pretty good about our data. Although this was not a true all-facility, 30-day readmission rate, we felt it had to be a reasonable proxy for the true rate, which we could not obtain.

We looked to benchmark ourselves because we had no reference for comparison. CMS refers frequently to an approximate 20% readmission rate across the nation; we felt good because our rates were significantly lower. We did some like-facility comparisons, and our rate was still a little better than those facilities, so we continued to feel good.

For those of you who prefer more exact numbers, MedPac reported in June 2007 that 17.6% of admissions resulted in a readmission within 30 days, accounting for about $15 billion in Medicare spending. Further, 6% of admissions resulted in a seven-day readmission rate.

I admit from personal experience that the number CMS touts has always boggled my mind to a degree. This means that almost one in five patients returns to a hospital within 30 days. Having worked in a variety of hospitals and communities, I couldn’t imagine a rate this high. I had never seen patients bouncing back that often.

To me, this simply reaffirmed the hypothesis that healthcare has a serious problem with continuity of care and communication. But this was not my hospital’s problem—we were better than 20%! This was a problem for communities with a poor primary care base or perhaps a community without hospitalists to efficiently take care of inpatients.

But it turns out I fell into a classic leadership trap: thinking we are better than we really are.

Several months ago, I was sitting in a meeting with the quality and patient safety staff, when one of the outcomes managers passed a report to me from CMS. It was the “Pepper Report,” which CMS had begun sending to all hospitals in the past year. One of the key bits of data in this report is the hospital’s 30-day readmit rate. Because CMS is able to gather data from all facilities, this is the true readmit rate—at least for the Medicare population. Ours was approximately 17%. I was immediately deflated.

But like the optimistic person I am, I immediately saw a burning platform for change and began to plan our attack on this problem.

What is our chief tactic? A good discharge. I am convinced more than ever that we simply need to focus on a better discharge.

I am not alone in this thinking. Almost from the beginning of the hospitalist movement, we have focused on the “black hole,” that period of time from discharge to first followup appointment. Many of you who have come to SHM meetings have attended discharge planning and transitions of care sessions. We have worked closely with the Hartford Foundation in developing a good discharge for elderly patients. Part of this effort resulted in discharge checklist you will find on the SHM Web site (www.hospitalmedicine.org). The next version of this is Project BOOST (Better Outcomes for Older Adults through Safe Transitions), led by Mark V. Williams, MD, principal investigator on the project and professor and chief of the Division of Hospital Medicine at the Feinberg School of Medicine at Northwestern University in Chicago.

In early June, a group of SHM leaders visited with MedPac, which advises Congress on Medicare policy. MedPac is interested in recommendations to improve the readmission rates in the U.S. If the plea to simply provide good medical care doesn’t move you, I hope the CMS “incentives” will.

What You Can Do

Focus on the good discharge. Many tactics are intuitive. Ensure that a succinct yet complete discharge summary is sent to the next physician in a timely manner. Clearly articulate a treatment plan not only immediately after discharge but for the next several months in general. Be sure to list all test results, their interpretation, and any pending at the time of discharge. Reconcile all medications from the admission list. Teach patients and families about the illness and what to do in certain circumstances.

These are just a few of the things to do. I am sure we will discover more or refine those we know. But by simply focusing on a good discharge, your program and hospital will be in good shape for the coming scrutiny. TH

Dr. Cawley is president of SHM.

How often are patients in your program readmitted in 30 days to any hospital? I know many of you monitor readmission rates back to your own program or facility. But if you examine the patient perspective, how often are patients you discharge being readmitted to any acute care hospital within 30 days?

Given the increasing frequency that the Centers for Medicare and Medicaid Services (CMS) is reporting about readmission rates, I asked my quality director to research our hospital’s data.

As would any reasonable chief medical officer (CMO), I figured we probably had some opportunities for improvement, but overall I felt the numbers were probably fine. Like any hospital I have worked in, we have a core group of patients who return to the hospital frequently. But from a working hospitalist perspective, it didn’t seem to be a problem in our hospital.

So, when the data returned, our initial impressions about the rates were reaffirmed. The overall hospital 30-day readmit rate to our hospital was about 6%. We looked across different payers, socioeconomic groups, discharging services, and diagnosis for areas of opportunity. We found that two populations had slightly higher rates of readmission—congestive heart failure (CHF) and sickle-cell pain crisis—but in general, there were no particular outliers.

I commissioned two quality improvement groups to begin looking at these areas, though I felt pretty good about our data. Although this was not a true all-facility, 30-day readmission rate, we felt it had to be a reasonable proxy for the true rate, which we could not obtain.

We looked to benchmark ourselves because we had no reference for comparison. CMS refers frequently to an approximate 20% readmission rate across the nation; we felt good because our rates were significantly lower. We did some like-facility comparisons, and our rate was still a little better than those facilities, so we continued to feel good.

For those of you who prefer more exact numbers, MedPac reported in June 2007 that 17.6% of admissions resulted in a readmission within 30 days, accounting for about $15 billion in Medicare spending. Further, 6% of admissions resulted in a seven-day readmission rate.

I admit from personal experience that the number CMS touts has always boggled my mind to a degree. This means that almost one in five patients returns to a hospital within 30 days. Having worked in a variety of hospitals and communities, I couldn’t imagine a rate this high. I had never seen patients bouncing back that often.

To me, this simply reaffirmed the hypothesis that healthcare has a serious problem with continuity of care and communication. But this was not my hospital’s problem—we were better than 20%! This was a problem for communities with a poor primary care base or perhaps a community without hospitalists to efficiently take care of inpatients.

But it turns out I fell into a classic leadership trap: thinking we are better than we really are.

Several months ago, I was sitting in a meeting with the quality and patient safety staff, when one of the outcomes managers passed a report to me from CMS. It was the “Pepper Report,” which CMS had begun sending to all hospitals in the past year. One of the key bits of data in this report is the hospital’s 30-day readmit rate. Because CMS is able to gather data from all facilities, this is the true readmit rate—at least for the Medicare population. Ours was approximately 17%. I was immediately deflated.

But like the optimistic person I am, I immediately saw a burning platform for change and began to plan our attack on this problem.

What is our chief tactic? A good discharge. I am convinced more than ever that we simply need to focus on a better discharge.

I am not alone in this thinking. Almost from the beginning of the hospitalist movement, we have focused on the “black hole,” that period of time from discharge to first followup appointment. Many of you who have come to SHM meetings have attended discharge planning and transitions of care sessions. We have worked closely with the Hartford Foundation in developing a good discharge for elderly patients. Part of this effort resulted in discharge checklist you will find on the SHM Web site (www.hospitalmedicine.org). The next version of this is Project BOOST (Better Outcomes for Older Adults through Safe Transitions), led by Mark V. Williams, MD, principal investigator on the project and professor and chief of the Division of Hospital Medicine at the Feinberg School of Medicine at Northwestern University in Chicago.

In early June, a group of SHM leaders visited with MedPac, which advises Congress on Medicare policy. MedPac is interested in recommendations to improve the readmission rates in the U.S. If the plea to simply provide good medical care doesn’t move you, I hope the CMS “incentives” will.

What You Can Do

Focus on the good discharge. Many tactics are intuitive. Ensure that a succinct yet complete discharge summary is sent to the next physician in a timely manner. Clearly articulate a treatment plan not only immediately after discharge but for the next several months in general. Be sure to list all test results, their interpretation, and any pending at the time of discharge. Reconcile all medications from the admission list. Teach patients and families about the illness and what to do in certain circumstances.

These are just a few of the things to do. I am sure we will discover more or refine those we know. But by simply focusing on a good discharge, your program and hospital will be in good shape for the coming scrutiny. TH

Dr. Cawley is president of SHM.

How often are patients in your program readmitted in 30 days to any hospital? I know many of you monitor readmission rates back to your own program or facility. But if you examine the patient perspective, how often are patients you discharge being readmitted to any acute care hospital within 30 days?

Given the increasing frequency that the Centers for Medicare and Medicaid Services (CMS) is reporting about readmission rates, I asked my quality director to research our hospital’s data.

As would any reasonable chief medical officer (CMO), I figured we probably had some opportunities for improvement, but overall I felt the numbers were probably fine. Like any hospital I have worked in, we have a core group of patients who return to the hospital frequently. But from a working hospitalist perspective, it didn’t seem to be a problem in our hospital.

So, when the data returned, our initial impressions about the rates were reaffirmed. The overall hospital 30-day readmit rate to our hospital was about 6%. We looked across different payers, socioeconomic groups, discharging services, and diagnosis for areas of opportunity. We found that two populations had slightly higher rates of readmission—congestive heart failure (CHF) and sickle-cell pain crisis—but in general, there were no particular outliers.

I commissioned two quality improvement groups to begin looking at these areas, though I felt pretty good about our data. Although this was not a true all-facility, 30-day readmission rate, we felt it had to be a reasonable proxy for the true rate, which we could not obtain.

We looked to benchmark ourselves because we had no reference for comparison. CMS refers frequently to an approximate 20% readmission rate across the nation; we felt good because our rates were significantly lower. We did some like-facility comparisons, and our rate was still a little better than those facilities, so we continued to feel good.

For those of you who prefer more exact numbers, MedPac reported in June 2007 that 17.6% of admissions resulted in a readmission within 30 days, accounting for about $15 billion in Medicare spending. Further, 6% of admissions resulted in a seven-day readmission rate.

I admit from personal experience that the number CMS touts has always boggled my mind to a degree. This means that almost one in five patients returns to a hospital within 30 days. Having worked in a variety of hospitals and communities, I couldn’t imagine a rate this high. I had never seen patients bouncing back that often.

To me, this simply reaffirmed the hypothesis that healthcare has a serious problem with continuity of care and communication. But this was not my hospital’s problem—we were better than 20%! This was a problem for communities with a poor primary care base or perhaps a community without hospitalists to efficiently take care of inpatients.

But it turns out I fell into a classic leadership trap: thinking we are better than we really are.

Several months ago, I was sitting in a meeting with the quality and patient safety staff, when one of the outcomes managers passed a report to me from CMS. It was the “Pepper Report,” which CMS had begun sending to all hospitals in the past year. One of the key bits of data in this report is the hospital’s 30-day readmit rate. Because CMS is able to gather data from all facilities, this is the true readmit rate—at least for the Medicare population. Ours was approximately 17%. I was immediately deflated.

But like the optimistic person I am, I immediately saw a burning platform for change and began to plan our attack on this problem.

What is our chief tactic? A good discharge. I am convinced more than ever that we simply need to focus on a better discharge.

I am not alone in this thinking. Almost from the beginning of the hospitalist movement, we have focused on the “black hole,” that period of time from discharge to first followup appointment. Many of you who have come to SHM meetings have attended discharge planning and transitions of care sessions. We have worked closely with the Hartford Foundation in developing a good discharge for elderly patients. Part of this effort resulted in discharge checklist you will find on the SHM Web site (www.hospitalmedicine.org). The next version of this is Project BOOST (Better Outcomes for Older Adults through Safe Transitions), led by Mark V. Williams, MD, principal investigator on the project and professor and chief of the Division of Hospital Medicine at the Feinberg School of Medicine at Northwestern University in Chicago.

In early June, a group of SHM leaders visited with MedPac, which advises Congress on Medicare policy. MedPac is interested in recommendations to improve the readmission rates in the U.S. If the plea to simply provide good medical care doesn’t move you, I hope the CMS “incentives” will.

What You Can Do

Focus on the good discharge. Many tactics are intuitive. Ensure that a succinct yet complete discharge summary is sent to the next physician in a timely manner. Clearly articulate a treatment plan not only immediately after discharge but for the next several months in general. Be sure to list all test results, their interpretation, and any pending at the time of discharge. Reconcile all medications from the admission list. Teach patients and families about the illness and what to do in certain circumstances.

These are just a few of the things to do. I am sure we will discover more or refine those we know. But by simply focusing on a good discharge, your program and hospital will be in good shape for the coming scrutiny. TH

Dr. Cawley is president of SHM.

Insanity is doing the same thing over and over again and expecting different results.—Albert Einstein

A hospitalist is defined as a provider whose primary professional focus is the general medical care of hospitalized patients.1

While this allows a concise, usable characterization of a hospitalist, it’s not the whole story. If it were, medical residents, nurses, and inpatient pharmacists all would be hospitalists.

Indeed, a traditional internist with a large hospital practice could reasonably deem him or herself a hospitalist. What defines what a hospitalist does, or should be doing—and how, if at all, is that different than what a traditional internist does in the hospital?

Education Deficiencies

Early data suggested a stark difference between outcomes attributed to hospitalists and general internists who rotated between the clinic and the hospital.

An early experience from the academic environment showed a hospitalist teaching model, when compared with a traditional teaching service, resulted in a 0.6-day length-of-stay (LOS) reduction and a cost savings of $700 per patient with no decrement in the quality of care, clinical outcomes, or satisfaction of provider, housestaff, or patient.2

Similar findings were revealed when community teaching and non-teaching hospitals transitioned to the hospitalist model.3-5 A 2002 review of 19 hospitalist studies revealed an average decreased LOS of 17% coupled with a 1% reduction in hospital costs per case.6

The year 2002 also saw, for the first time, published data that the hospitalist model could reduce in-hospital and 30-day mortality rates.7,8 Together with a 2004 paper showing reductions in minor post-operative complications with hospitalist comanagement of orthopedic patients, these studies suggested hospitalists’ care transcended mere cost savings, improving quality measures as well.9

More recently, however, Lindenauer, et al., found important but less robust differences between hospitalists and non-hospitalists.10 As compared with traditional internists, hospitalists reduced LOS 0.4 days and cost per patient by $268.

While these moderate reductions in LOS and cost versus traditional internists are statistically and clinically significant, they are less vigorous than previous findings. Despite some methodological concerns, this largest investigation—in terms of hospital sites (45), patients (76,926) and hospitalists (284)—revealed no demonstrable improvements in the quality outcomes measured.

Similarly, another recent publication found consultation, provided by medical subspecialists or hospitalists, did not improve glycemic control, rate of appropriate venous thromboembolism (VTE) prophylaxis or perioperative beta-blocker use compared with patients cared for by surgeons alone.11,12

While it is tempting to think hospitalists have re-engineered the systems of care to the point that any provider can fluently and adroitly care for patients, continued reports of less-than-optimal hospital outcomes do not support this hypothesis. More likely, the variance in the early and recent studies relates to the egress from the hospital of less capable or engaged non-hospitalist providers such that more recent findings reflect a comparator group that more closely approximates, in terms of clinical volume, hospitalists.

It’s time to reconsider how we document the merit of hospitalists. Continuing to benchmark hospitalists against non-hospitalists will not tell us if inpatient care is becoming safer, only how one group is doing compared with another. Nor will it necessarily lead to improvements in the quality of care.

To fulfill the promise of the hospitalist model, we need to ensure hospitalists are doing it better, not just better than an external comparator group. As such, it would be more valuable to evaluate hospitalists today versus those five years ago. If, as I suspect, there would be little difference in the clinical outcomes between a new hospitalist (or one in practice for three years) in 2003 and one in 2008 and we accept that hospitalist care has yet to achieve its pinnacle then we must adopt a new path. This will require redesigning the way we train hospitalists.

The ineffectiveness of our current training system is playing out in Dr. Lindenauer’s New England Journal of Medicine paper last year. He found hospitalist outcomes are only marginally better than their similarly trained traditional internist colleagues. To expect differences is to succumb to Albert Einstein’s definition of insanity. We simply cannot expect hospitalists to improve the quality of care with the same set of tools that didn’t allow our predecessors to do so.

Hospitalist-Focused Curricula

Several studies have evaluated the gap between internal medicine (IM) training and hospital medicine practice. A 2007 paper reported that nearly 30% of a community hospitalist practice consisted of areas of under emphasis in traditional IM training.13

These include consultative medicine (6.4% of practice) and the care of the patients with neurological (13.4%), orthopedic (6.4%), or general surgical (2.2%) issues. Additionally, nearly 50% of their practice consisted of patients older than 65, with the largest subset of patients ages 75-84.

Yet, most IM residency training programs do not adequately train housestaff to care for these types of patients and problems. Plauth, et al., documented areas of educational deficiencies by surveying several hundred IM-trained hospitalists about their preparedness to practice hospital medicine following residency training.14

The respondents reported feeling unprepared to care for the type and amount of neurology, geriatrics, palliative care and consultative and perioperative medicine they encountered.

Additionally, they were ill-equipped for the myriad quality improvement and systems and transitions-of-care issues they faced daily.

The “2005-2006 SHM Survey: State of the Hospital Medicine Movement” further highlighted the level of hospitalist non-clinical work, showing that 86% of hospitalist groups engage in quality improvement, 72% contribute practice guidelines, 54% work in utilization review, and 54% are involved in developing electronic medical records and provider order entry.15

For the hospitalist model to deliver outcomes superior to our traditional care model, we will need to create training programs that provide hospitalists with the skills current IM graduates do not possess.

Training programs must evolve to include the necessary clinical and non-clinical aspects of this new medical specialty. Hospitalists have populated the American healthcare landscape for more than a decade, yet very few training programs support innovation in the field of hospital medicine.

It is past time for IM educators, many of whom are hospitalists, to bridge this educational chasm through curricular reform. Short of this, the hospital medicine movement will achieve its pinnacle well short of its promise. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Society of Hospital Medicine. General information about SHM. Available at: www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm. Accessed April 25, 2008.
2. Wachter RB, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service. JAMA. 1998;279:1560-1565.
3. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197-203.
4. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med. 1999;130:350-354.
5. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: The Kaiser Permanente experience. Ann Intern Med. 1999;130:355-359.
6. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
7. Meltzer D, Manning W, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
9. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004;141:28-38.
10. Lindenauer PK, Rothber MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalist, general internists, and family physicians. N Engl J Med. 2007;357:2589-600.
11. Dr Andrew Auerbach, personal communication, January 7, 2008.
12. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167:2338-2344.
13. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice, a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
14. Plauth WH, Pantilat SZ, Wachter RM et al. Hospitalist’s perceptions of their residency training needs: Results of a national survey. Am J Med. 2001;111:247-254.
15. Society of Hospital Medicine. 2005-2006 SHM Survey: State of the Hospital Medicine Movement. Available at: http://dev.hospitalmedicine.org/AM/Template.cfm?Section=Survey&Template=/CM/ContentDisplay.cfm&ContentID=14352. Accessed April 28, 2008.

Insanity is doing the same thing over and over again and expecting different results.—Albert Einstein

A hospitalist is defined as a provider whose primary professional focus is the general medical care of hospitalized patients.1

While this allows a concise, usable characterization of a hospitalist, it’s not the whole story. If it were, medical residents, nurses, and inpatient pharmacists all would be hospitalists.

Indeed, a traditional internist with a large hospital practice could reasonably deem him or herself a hospitalist. What defines what a hospitalist does, or should be doing—and how, if at all, is that different than what a traditional internist does in the hospital?

Education Deficiencies

Early data suggested a stark difference between outcomes attributed to hospitalists and general internists who rotated between the clinic and the hospital.

An early experience from the academic environment showed a hospitalist teaching model, when compared with a traditional teaching service, resulted in a 0.6-day length-of-stay (LOS) reduction and a cost savings of $700 per patient with no decrement in the quality of care, clinical outcomes, or satisfaction of provider, housestaff, or patient.2

Similar findings were revealed when community teaching and non-teaching hospitals transitioned to the hospitalist model.3-5 A 2002 review of 19 hospitalist studies revealed an average decreased LOS of 17% coupled with a 1% reduction in hospital costs per case.6

The year 2002 also saw, for the first time, published data that the hospitalist model could reduce in-hospital and 30-day mortality rates.7,8 Together with a 2004 paper showing reductions in minor post-operative complications with hospitalist comanagement of orthopedic patients, these studies suggested hospitalists’ care transcended mere cost savings, improving quality measures as well.9

More recently, however, Lindenauer, et al., found important but less robust differences between hospitalists and non-hospitalists.10 As compared with traditional internists, hospitalists reduced LOS 0.4 days and cost per patient by $268.

While these moderate reductions in LOS and cost versus traditional internists are statistically and clinically significant, they are less vigorous than previous findings. Despite some methodological concerns, this largest investigation—in terms of hospital sites (45), patients (76,926) and hospitalists (284)—revealed no demonstrable improvements in the quality outcomes measured.

Similarly, another recent publication found consultation, provided by medical subspecialists or hospitalists, did not improve glycemic control, rate of appropriate venous thromboembolism (VTE) prophylaxis or perioperative beta-blocker use compared with patients cared for by surgeons alone.11,12

While it is tempting to think hospitalists have re-engineered the systems of care to the point that any provider can fluently and adroitly care for patients, continued reports of less-than-optimal hospital outcomes do not support this hypothesis. More likely, the variance in the early and recent studies relates to the egress from the hospital of less capable or engaged non-hospitalist providers such that more recent findings reflect a comparator group that more closely approximates, in terms of clinical volume, hospitalists.

It’s time to reconsider how we document the merit of hospitalists. Continuing to benchmark hospitalists against non-hospitalists will not tell us if inpatient care is becoming safer, only how one group is doing compared with another. Nor will it necessarily lead to improvements in the quality of care.

To fulfill the promise of the hospitalist model, we need to ensure hospitalists are doing it better, not just better than an external comparator group. As such, it would be more valuable to evaluate hospitalists today versus those five years ago. If, as I suspect, there would be little difference in the clinical outcomes between a new hospitalist (or one in practice for three years) in 2003 and one in 2008 and we accept that hospitalist care has yet to achieve its pinnacle then we must adopt a new path. This will require redesigning the way we train hospitalists.

The ineffectiveness of our current training system is playing out in Dr. Lindenauer’s New England Journal of Medicine paper last year. He found hospitalist outcomes are only marginally better than their similarly trained traditional internist colleagues. To expect differences is to succumb to Albert Einstein’s definition of insanity. We simply cannot expect hospitalists to improve the quality of care with the same set of tools that didn’t allow our predecessors to do so.

Hospitalist-Focused Curricula

Several studies have evaluated the gap between internal medicine (IM) training and hospital medicine practice. A 2007 paper reported that nearly 30% of a community hospitalist practice consisted of areas of under emphasis in traditional IM training.13

These include consultative medicine (6.4% of practice) and the care of the patients with neurological (13.4%), orthopedic (6.4%), or general surgical (2.2%) issues. Additionally, nearly 50% of their practice consisted of patients older than 65, with the largest subset of patients ages 75-84.

Yet, most IM residency training programs do not adequately train housestaff to care for these types of patients and problems. Plauth, et al., documented areas of educational deficiencies by surveying several hundred IM-trained hospitalists about their preparedness to practice hospital medicine following residency training.14

The respondents reported feeling unprepared to care for the type and amount of neurology, geriatrics, palliative care and consultative and perioperative medicine they encountered.

Additionally, they were ill-equipped for the myriad quality improvement and systems and transitions-of-care issues they faced daily.

The “2005-2006 SHM Survey: State of the Hospital Medicine Movement” further highlighted the level of hospitalist non-clinical work, showing that 86% of hospitalist groups engage in quality improvement, 72% contribute practice guidelines, 54% work in utilization review, and 54% are involved in developing electronic medical records and provider order entry.15

For the hospitalist model to deliver outcomes superior to our traditional care model, we will need to create training programs that provide hospitalists with the skills current IM graduates do not possess.

Training programs must evolve to include the necessary clinical and non-clinical aspects of this new medical specialty. Hospitalists have populated the American healthcare landscape for more than a decade, yet very few training programs support innovation in the field of hospital medicine.

It is past time for IM educators, many of whom are hospitalists, to bridge this educational chasm through curricular reform. Short of this, the hospital medicine movement will achieve its pinnacle well short of its promise. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Society of Hospital Medicine. General information about SHM. Available at: www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm. Accessed April 25, 2008.
2. Wachter RB, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service. JAMA. 1998;279:1560-1565.
3. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197-203.
4. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med. 1999;130:350-354.
5. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: The Kaiser Permanente experience. Ann Intern Med. 1999;130:355-359.
6. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
7. Meltzer D, Manning W, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
9. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004;141:28-38.
10. Lindenauer PK, Rothber MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalist, general internists, and family physicians. N Engl J Med. 2007;357:2589-600.
11. Dr Andrew Auerbach, personal communication, January 7, 2008.
12. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167:2338-2344.
13. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice, a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
14. Plauth WH, Pantilat SZ, Wachter RM et al. Hospitalist’s perceptions of their residency training needs: Results of a national survey. Am J Med. 2001;111:247-254.
15. Society of Hospital Medicine. 2005-2006 SHM Survey: State of the Hospital Medicine Movement. Available at: http://dev.hospitalmedicine.org/AM/Template.cfm?Section=Survey&Template=/CM/ContentDisplay.cfm&ContentID=14352. Accessed April 28, 2008.

Insanity is doing the same thing over and over again and expecting different results.—Albert Einstein

A hospitalist is defined as a provider whose primary professional focus is the general medical care of hospitalized patients.1

While this allows a concise, usable characterization of a hospitalist, it’s not the whole story. If it were, medical residents, nurses, and inpatient pharmacists all would be hospitalists.

Indeed, a traditional internist with a large hospital practice could reasonably deem him or herself a hospitalist. What defines what a hospitalist does, or should be doing—and how, if at all, is that different than what a traditional internist does in the hospital?

Education Deficiencies

Early data suggested a stark difference between outcomes attributed to hospitalists and general internists who rotated between the clinic and the hospital.

An early experience from the academic environment showed a hospitalist teaching model, when compared with a traditional teaching service, resulted in a 0.6-day length-of-stay (LOS) reduction and a cost savings of $700 per patient with no decrement in the quality of care, clinical outcomes, or satisfaction of provider, housestaff, or patient.2

Similar findings were revealed when community teaching and non-teaching hospitals transitioned to the hospitalist model.3-5 A 2002 review of 19 hospitalist studies revealed an average decreased LOS of 17% coupled with a 1% reduction in hospital costs per case.6

The year 2002 also saw, for the first time, published data that the hospitalist model could reduce in-hospital and 30-day mortality rates.7,8 Together with a 2004 paper showing reductions in minor post-operative complications with hospitalist comanagement of orthopedic patients, these studies suggested hospitalists’ care transcended mere cost savings, improving quality measures as well.9

More recently, however, Lindenauer, et al., found important but less robust differences between hospitalists and non-hospitalists.10 As compared with traditional internists, hospitalists reduced LOS 0.4 days and cost per patient by $268.

While these moderate reductions in LOS and cost versus traditional internists are statistically and clinically significant, they are less vigorous than previous findings. Despite some methodological concerns, this largest investigation—in terms of hospital sites (45), patients (76,926) and hospitalists (284)—revealed no demonstrable improvements in the quality outcomes measured.

Similarly, another recent publication found consultation, provided by medical subspecialists or hospitalists, did not improve glycemic control, rate of appropriate venous thromboembolism (VTE) prophylaxis or perioperative beta-blocker use compared with patients cared for by surgeons alone.11,12

While it is tempting to think hospitalists have re-engineered the systems of care to the point that any provider can fluently and adroitly care for patients, continued reports of less-than-optimal hospital outcomes do not support this hypothesis. More likely, the variance in the early and recent studies relates to the egress from the hospital of less capable or engaged non-hospitalist providers such that more recent findings reflect a comparator group that more closely approximates, in terms of clinical volume, hospitalists.

It’s time to reconsider how we document the merit of hospitalists. Continuing to benchmark hospitalists against non-hospitalists will not tell us if inpatient care is becoming safer, only how one group is doing compared with another. Nor will it necessarily lead to improvements in the quality of care.

To fulfill the promise of the hospitalist model, we need to ensure hospitalists are doing it better, not just better than an external comparator group. As such, it would be more valuable to evaluate hospitalists today versus those five years ago. If, as I suspect, there would be little difference in the clinical outcomes between a new hospitalist (or one in practice for three years) in 2003 and one in 2008 and we accept that hospitalist care has yet to achieve its pinnacle then we must adopt a new path. This will require redesigning the way we train hospitalists.

The ineffectiveness of our current training system is playing out in Dr. Lindenauer’s New England Journal of Medicine paper last year. He found hospitalist outcomes are only marginally better than their similarly trained traditional internist colleagues. To expect differences is to succumb to Albert Einstein’s definition of insanity. We simply cannot expect hospitalists to improve the quality of care with the same set of tools that didn’t allow our predecessors to do so.

Hospitalist-Focused Curricula

Several studies have evaluated the gap between internal medicine (IM) training and hospital medicine practice. A 2007 paper reported that nearly 30% of a community hospitalist practice consisted of areas of under emphasis in traditional IM training.13

These include consultative medicine (6.4% of practice) and the care of the patients with neurological (13.4%), orthopedic (6.4%), or general surgical (2.2%) issues. Additionally, nearly 50% of their practice consisted of patients older than 65, with the largest subset of patients ages 75-84.

Yet, most IM residency training programs do not adequately train housestaff to care for these types of patients and problems. Plauth, et al., documented areas of educational deficiencies by surveying several hundred IM-trained hospitalists about their preparedness to practice hospital medicine following residency training.14

The respondents reported feeling unprepared to care for the type and amount of neurology, geriatrics, palliative care and consultative and perioperative medicine they encountered.

Additionally, they were ill-equipped for the myriad quality improvement and systems and transitions-of-care issues they faced daily.

The “2005-2006 SHM Survey: State of the Hospital Medicine Movement” further highlighted the level of hospitalist non-clinical work, showing that 86% of hospitalist groups engage in quality improvement, 72% contribute practice guidelines, 54% work in utilization review, and 54% are involved in developing electronic medical records and provider order entry.15

For the hospitalist model to deliver outcomes superior to our traditional care model, we will need to create training programs that provide hospitalists with the skills current IM graduates do not possess.

Training programs must evolve to include the necessary clinical and non-clinical aspects of this new medical specialty. Hospitalists have populated the American healthcare landscape for more than a decade, yet very few training programs support innovation in the field of hospital medicine.

It is past time for IM educators, many of whom are hospitalists, to bridge this educational chasm through curricular reform. Short of this, the hospital medicine movement will achieve its pinnacle well short of its promise. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Society of Hospital Medicine. General information about SHM. Available at: www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm. Accessed April 25, 2008.
2. Wachter RB, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service. JAMA. 1998;279:1560-1565.
3. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197-203.
4. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med. 1999;130:350-354.
5. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: The Kaiser Permanente experience. Ann Intern Med. 1999;130:355-359.
6. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
7. Meltzer D, Manning W, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
9. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004;141:28-38.
10. Lindenauer PK, Rothber MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalist, general internists, and family physicians. N Engl J Med. 2007;357:2589-600.
11. Dr Andrew Auerbach, personal communication, January 7, 2008.
12. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167:2338-2344.
13. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice, a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
14. Plauth WH, Pantilat SZ, Wachter RM et al. Hospitalist’s perceptions of their residency training needs: Results of a national survey. Am J Med. 2001;111:247-254.
15. Society of Hospital Medicine. 2005-2006 SHM Survey: State of the Hospital Medicine Movement. Available at: http://dev.hospitalmedicine.org/AM/Template.cfm?Section=Survey&Template=/CM/ContentDisplay.cfm&ContentID=14352. Accessed April 28, 2008.