Jeff Glasheen, MD, FHM

The world is atwitter over Twitter—the social networking utility that allows users to send immediate, 140-character text messages known as “tweets.” From then-presidential-nominee Barack Obama updating the masses on his campaign travels to actor Ashton Kutcher challenging the entire CNN news organization to a Twitter challenge (the former beat the latter by achieving 1 million Twitter followers first) to Britney Spears micro-blogging updates from her ever-so-fascinating life, Twitter is all the rage. The site describes its mission as allowing friends and family to stay connected through quick, frequent text answers to one question: “What are you doing?”

Not one to be left out, I thought I’d give it a shot. However, my tweeting ability is hamstrung by two serious insufficiencies: First, I’m a technology buffoon. Second, there’s no way I can keep my glorious insights to 140 characters.

So, with respect to the folks at Twitter, here’s a not-so-real-time chronicle of how I spent my time at HM09 in Chicago.

Us vs. Them?

The main session opened with a panel discussion about the future role of hospitalist leaders. The most poignant moment came when the panel of chief medical officers was asked how they viewed hospitalists. One recognized the tremendous potential hospitalists offer as the go-to resource for tackling important quality, efficiency, and process issues. This was countered by another participant warning that this potential can go untapped when HM group leaders function as “union stewards,” protecting hospitalists’ interests without a thought to the greater needs of the hospital. While recognizing advocacy as an important part of a group leader’s job, the message was clear: Too much advocacy can create an adversarial relationship that undermines our great potential. (That’s 769 characters.)

Laws Are Like Sausages: It’s Best Not to Watch Them Being Made

Mark Chassin, MD, MPP, MPH, president of The Joint Commission, discussed the quality revolution. He outlined the growing need and role of hospitalists in crossing the hospital quality chasm. He fired a cautionary shot across our bow by noting the increasing shortcomings of the public-private enterprise in improving healthcare quality. His clear concern is that if we don’t improve quality drastically, the government will step in and pass legislation—something that would most likely impact hospitals and hospitalists negatively. (532)

“Rack-da-poo”

A highly informative physician roundtable tackled value-based purchasing. The Reporting Hospital Quality Data for Annual Payment Update, or RHQDAPU—pronounced “rack-da-poo”—is a voluntary (insofar as hospitals who don’t comply lose 2% of Medicare reimbursement) hospital reporting system for adherence to core measures. This program, widely viewed as the foundation for future hospital pay for performance, will be a budget-neutral process such that some hospitals will win while an equal number will lose. Up to 5% of hospital reimbursement could be at risk. Data is available at www.hospital compare.gov. Check out your hospital; your patients already are. (659)

The Eagle Has Landed

At the end of the first day I co-chaired the Academic/Research special-interest forum with David Meltzer, MD, PhD, of the University of Chicago. The group grappled with a number of questions, from struggles with QI work to finding ways to support research to the development of young academicians. One comment, from Kim Eagle, MD, a world-renowned cardiologist at the University of Michigan and SHM’s visiting professor, resonated with the group. Dr. Eagle sagely responded to a young physician having difficulty developing a research interest by stating research is not about research but about answering questions. In the current healthcare environment, there are more than enough questions to launch all of our academic careers. (734)

Is HM Intensive Enough?

The second day got off to a roaring start with the best of the Research, Innovations and Clinical Vignettes (RIV). The most hotly anticipated research was from Emory University, where Kristin Wise, MD, and her colleagues evaluated an intensivist vs. hospitalist model for ICU staffing and found that after correction for baseline differences in acute illnesses, overall there were no differences in mortality between the two groups. Despite being constrained by methodological differences between the comparator groups and a lack of randomization, the data represents an important first step in addressing the huge shortfall of intensivist providers. (650)

Why My Wife Never Listens

Vinny Arora, MD, MA, of the University of Chicago and Erin R. Stucky, MD, of Rady Children’s Hospital in San Diego addressed the tremendously important topic of improving in-hospital handoffs. Part of the problem, they noted, is the egocentric heuristic. This cognitive shortcoming results in the sender believing that they are clearly expressing themselves because the message is apparent to them. Research shows that 40% of the time, the piece of information deemed most important by the sender is not identified as such by the recipient. Disconnect increases the better the sender knows the recipient, which explains much of our difficulty communicating in the hospital and domestically. Overcoming this requires vigilance on the sender’s part to be sure the message is accurately conveyed. (793)

Could We Go Bankrupt?

We all have too many patients and not enough providers. Thus, I was shocked when Scott F. Enderby, MD, of East Bay Physicians Medical Group in San Francisco spoke of a hospitalist group that went from profitability to bankruptcy in one year after adding four new employees. In his Finance 101 session, we learned how it happened despite an expected increase in clinical revenue: The group was constrained by a lack of liquidity that was retrospectively obvious from their balance sheet and operations and cash flow statements. Considering that more than a third of hospitalist directors do not know their group’s most basic financial metrics, this was a reminder that many more of us may be at risk in this increasingly unforgiving economy. (741)

Wachter’s World

As has become an annual meeting tradition, HM pioneer Robert Wachter, MD, FHM, professor and associate chairman of the department of medicine at the University of California at San Francisco, closed the meeting with his uniquely insightful comments on the state of healthcare. In using a case of mistaken identity he adeptly illustrated many of the key safety problems we face in healthcare. Further, he called for a transition away from a “no blame” medical culture to one of accountability. Once again, Dr. Wachter proved that despite going last, he continues to be out in front. (582)

A Child’s Calming Touch

This was my seventh consecutive annual meeting, and like the six before, it has exceeded my every expectation. From knowledge gained to the chance to speak and share my research to the opportunity to network and catch up with friends, the meeting was filled with lasting memories. Still, at times my hectic schedule bordered on chaos. It was during those times that I turned to a short, 23-second voicemail my wife sent the first day. On it my son, almost 2 years old, is belly-laughing as only a child can—pure, unbridled, carefree.

For me, it acted as a mariner, calming me at the end of a busy day, serving as a reminder of the important things in life, guiding me home. (674)

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.

The world is atwitter over Twitter—the social networking utility that allows users to send immediate, 140-character text messages known as “tweets.” From then-presidential-nominee Barack Obama updating the masses on his campaign travels to actor Ashton Kutcher challenging the entire CNN news organization to a Twitter challenge (the former beat the latter by achieving 1 million Twitter followers first) to Britney Spears micro-blogging updates from her ever-so-fascinating life, Twitter is all the rage. The site describes its mission as allowing friends and family to stay connected through quick, frequent text answers to one question: “What are you doing?”

Not one to be left out, I thought I’d give it a shot. However, my tweeting ability is hamstrung by two serious insufficiencies: First, I’m a technology buffoon. Second, there’s no way I can keep my glorious insights to 140 characters.

So, with respect to the folks at Twitter, here’s a not-so-real-time chronicle of how I spent my time at HM09 in Chicago.

Us vs. Them?

The main session opened with a panel discussion about the future role of hospitalist leaders. The most poignant moment came when the panel of chief medical officers was asked how they viewed hospitalists. One recognized the tremendous potential hospitalists offer as the go-to resource for tackling important quality, efficiency, and process issues. This was countered by another participant warning that this potential can go untapped when HM group leaders function as “union stewards,” protecting hospitalists’ interests without a thought to the greater needs of the hospital. While recognizing advocacy as an important part of a group leader’s job, the message was clear: Too much advocacy can create an adversarial relationship that undermines our great potential. (That’s 769 characters.)

Laws Are Like Sausages: It’s Best Not to Watch Them Being Made

Mark Chassin, MD, MPP, MPH, president of The Joint Commission, discussed the quality revolution. He outlined the growing need and role of hospitalists in crossing the hospital quality chasm. He fired a cautionary shot across our bow by noting the increasing shortcomings of the public-private enterprise in improving healthcare quality. His clear concern is that if we don’t improve quality drastically, the government will step in and pass legislation—something that would most likely impact hospitals and hospitalists negatively. (532)

“Rack-da-poo”

A highly informative physician roundtable tackled value-based purchasing. The Reporting Hospital Quality Data for Annual Payment Update, or RHQDAPU—pronounced “rack-da-poo”—is a voluntary (insofar as hospitals who don’t comply lose 2% of Medicare reimbursement) hospital reporting system for adherence to core measures. This program, widely viewed as the foundation for future hospital pay for performance, will be a budget-neutral process such that some hospitals will win while an equal number will lose. Up to 5% of hospital reimbursement could be at risk. Data is available at www.hospital compare.gov. Check out your hospital; your patients already are. (659)

The Eagle Has Landed

At the end of the first day I co-chaired the Academic/Research special-interest forum with David Meltzer, MD, PhD, of the University of Chicago. The group grappled with a number of questions, from struggles with QI work to finding ways to support research to the development of young academicians. One comment, from Kim Eagle, MD, a world-renowned cardiologist at the University of Michigan and SHM’s visiting professor, resonated with the group. Dr. Eagle sagely responded to a young physician having difficulty developing a research interest by stating research is not about research but about answering questions. In the current healthcare environment, there are more than enough questions to launch all of our academic careers. (734)

Is HM Intensive Enough?

The second day got off to a roaring start with the best of the Research, Innovations and Clinical Vignettes (RIV). The most hotly anticipated research was from Emory University, where Kristin Wise, MD, and her colleagues evaluated an intensivist vs. hospitalist model for ICU staffing and found that after correction for baseline differences in acute illnesses, overall there were no differences in mortality between the two groups. Despite being constrained by methodological differences between the comparator groups and a lack of randomization, the data represents an important first step in addressing the huge shortfall of intensivist providers. (650)

Why My Wife Never Listens

Vinny Arora, MD, MA, of the University of Chicago and Erin R. Stucky, MD, of Rady Children’s Hospital in San Diego addressed the tremendously important topic of improving in-hospital handoffs. Part of the problem, they noted, is the egocentric heuristic. This cognitive shortcoming results in the sender believing that they are clearly expressing themselves because the message is apparent to them. Research shows that 40% of the time, the piece of information deemed most important by the sender is not identified as such by the recipient. Disconnect increases the better the sender knows the recipient, which explains much of our difficulty communicating in the hospital and domestically. Overcoming this requires vigilance on the sender’s part to be sure the message is accurately conveyed. (793)

Could We Go Bankrupt?

We all have too many patients and not enough providers. Thus, I was shocked when Scott F. Enderby, MD, of East Bay Physicians Medical Group in San Francisco spoke of a hospitalist group that went from profitability to bankruptcy in one year after adding four new employees. In his Finance 101 session, we learned how it happened despite an expected increase in clinical revenue: The group was constrained by a lack of liquidity that was retrospectively obvious from their balance sheet and operations and cash flow statements. Considering that more than a third of hospitalist directors do not know their group’s most basic financial metrics, this was a reminder that many more of us may be at risk in this increasingly unforgiving economy. (741)

Wachter’s World

As has become an annual meeting tradition, HM pioneer Robert Wachter, MD, FHM, professor and associate chairman of the department of medicine at the University of California at San Francisco, closed the meeting with his uniquely insightful comments on the state of healthcare. In using a case of mistaken identity he adeptly illustrated many of the key safety problems we face in healthcare. Further, he called for a transition away from a “no blame” medical culture to one of accountability. Once again, Dr. Wachter proved that despite going last, he continues to be out in front. (582)

A Child’s Calming Touch

This was my seventh consecutive annual meeting, and like the six before, it has exceeded my every expectation. From knowledge gained to the chance to speak and share my research to the opportunity to network and catch up with friends, the meeting was filled with lasting memories. Still, at times my hectic schedule bordered on chaos. It was during those times that I turned to a short, 23-second voicemail my wife sent the first day. On it my son, almost 2 years old, is belly-laughing as only a child can—pure, unbridled, carefree.

For me, it acted as a mariner, calming me at the end of a busy day, serving as a reminder of the important things in life, guiding me home. (674)

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.

The world is atwitter over Twitter—the social networking utility that allows users to send immediate, 140-character text messages known as “tweets.” From then-presidential-nominee Barack Obama updating the masses on his campaign travels to actor Ashton Kutcher challenging the entire CNN news organization to a Twitter challenge (the former beat the latter by achieving 1 million Twitter followers first) to Britney Spears micro-blogging updates from her ever-so-fascinating life, Twitter is all the rage. The site describes its mission as allowing friends and family to stay connected through quick, frequent text answers to one question: “What are you doing?”

Not one to be left out, I thought I’d give it a shot. However, my tweeting ability is hamstrung by two serious insufficiencies: First, I’m a technology buffoon. Second, there’s no way I can keep my glorious insights to 140 characters.

So, with respect to the folks at Twitter, here’s a not-so-real-time chronicle of how I spent my time at HM09 in Chicago.

Us vs. Them?

The main session opened with a panel discussion about the future role of hospitalist leaders. The most poignant moment came when the panel of chief medical officers was asked how they viewed hospitalists. One recognized the tremendous potential hospitalists offer as the go-to resource for tackling important quality, efficiency, and process issues. This was countered by another participant warning that this potential can go untapped when HM group leaders function as “union stewards,” protecting hospitalists’ interests without a thought to the greater needs of the hospital. While recognizing advocacy as an important part of a group leader’s job, the message was clear: Too much advocacy can create an adversarial relationship that undermines our great potential. (That’s 769 characters.)

Laws Are Like Sausages: It’s Best Not to Watch Them Being Made

Mark Chassin, MD, MPP, MPH, president of The Joint Commission, discussed the quality revolution. He outlined the growing need and role of hospitalists in crossing the hospital quality chasm. He fired a cautionary shot across our bow by noting the increasing shortcomings of the public-private enterprise in improving healthcare quality. His clear concern is that if we don’t improve quality drastically, the government will step in and pass legislation—something that would most likely impact hospitals and hospitalists negatively. (532)

“Rack-da-poo”

A highly informative physician roundtable tackled value-based purchasing. The Reporting Hospital Quality Data for Annual Payment Update, or RHQDAPU—pronounced “rack-da-poo”—is a voluntary (insofar as hospitals who don’t comply lose 2% of Medicare reimbursement) hospital reporting system for adherence to core measures. This program, widely viewed as the foundation for future hospital pay for performance, will be a budget-neutral process such that some hospitals will win while an equal number will lose. Up to 5% of hospital reimbursement could be at risk. Data is available at www.hospital compare.gov. Check out your hospital; your patients already are. (659)

The Eagle Has Landed

At the end of the first day I co-chaired the Academic/Research special-interest forum with David Meltzer, MD, PhD, of the University of Chicago. The group grappled with a number of questions, from struggles with QI work to finding ways to support research to the development of young academicians. One comment, from Kim Eagle, MD, a world-renowned cardiologist at the University of Michigan and SHM’s visiting professor, resonated with the group. Dr. Eagle sagely responded to a young physician having difficulty developing a research interest by stating research is not about research but about answering questions. In the current healthcare environment, there are more than enough questions to launch all of our academic careers. (734)

Is HM Intensive Enough?

The second day got off to a roaring start with the best of the Research, Innovations and Clinical Vignettes (RIV). The most hotly anticipated research was from Emory University, where Kristin Wise, MD, and her colleagues evaluated an intensivist vs. hospitalist model for ICU staffing and found that after correction for baseline differences in acute illnesses, overall there were no differences in mortality between the two groups. Despite being constrained by methodological differences between the comparator groups and a lack of randomization, the data represents an important first step in addressing the huge shortfall of intensivist providers. (650)

Why My Wife Never Listens

Vinny Arora, MD, MA, of the University of Chicago and Erin R. Stucky, MD, of Rady Children’s Hospital in San Diego addressed the tremendously important topic of improving in-hospital handoffs. Part of the problem, they noted, is the egocentric heuristic. This cognitive shortcoming results in the sender believing that they are clearly expressing themselves because the message is apparent to them. Research shows that 40% of the time, the piece of information deemed most important by the sender is not identified as such by the recipient. Disconnect increases the better the sender knows the recipient, which explains much of our difficulty communicating in the hospital and domestically. Overcoming this requires vigilance on the sender’s part to be sure the message is accurately conveyed. (793)

Could We Go Bankrupt?

We all have too many patients and not enough providers. Thus, I was shocked when Scott F. Enderby, MD, of East Bay Physicians Medical Group in San Francisco spoke of a hospitalist group that went from profitability to bankruptcy in one year after adding four new employees. In his Finance 101 session, we learned how it happened despite an expected increase in clinical revenue: The group was constrained by a lack of liquidity that was retrospectively obvious from their balance sheet and operations and cash flow statements. Considering that more than a third of hospitalist directors do not know their group’s most basic financial metrics, this was a reminder that many more of us may be at risk in this increasingly unforgiving economy. (741)

Wachter’s World

As has become an annual meeting tradition, HM pioneer Robert Wachter, MD, FHM, professor and associate chairman of the department of medicine at the University of California at San Francisco, closed the meeting with his uniquely insightful comments on the state of healthcare. In using a case of mistaken identity he adeptly illustrated many of the key safety problems we face in healthcare. Further, he called for a transition away from a “no blame” medical culture to one of accountability. Once again, Dr. Wachter proved that despite going last, he continues to be out in front. (582)

A Child’s Calming Touch

This was my seventh consecutive annual meeting, and like the six before, it has exceeded my every expectation. From knowledge gained to the chance to speak and share my research to the opportunity to network and catch up with friends, the meeting was filled with lasting memories. Still, at times my hectic schedule bordered on chaos. It was during those times that I turned to a short, 23-second voicemail my wife sent the first day. On it my son, almost 2 years old, is belly-laughing as only a child can—pure, unbridled, carefree.

For me, it acted as a mariner, calming me at the end of a busy day, serving as a reminder of the important things in life, guiding me home. (674)

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.

In the aftermath of the recent shuttering of Colorado’s oldest newspaper, The Rocky Mountain News, a couple of colleagues and I were discussing how unlikely it seemed just a few months ago that this could happen. It wasn’t long until we made the theoretical leap to what it would take for our hospitalist group to go out of business. Of course, this seems highly unlikely, but then again, the closing of a 150-year-old metropolitan newspaper seemed a preposterous proposition.

In the course of this discussion, we conjured myriad internal or external factors that could adversely affect our program. Although this was a tangential, lunchtime discussion, it did reverberate against the tuning fork of a faltering U.S. economy, especially regarding the financial sector and the automotive industry.

With that as a frame, I thought I’d take a dip into Paranoia Pond and look at potential threats to the HM model. Let me start by saying that I believe—deeply—in the hospitalist movement, the strides we’ve made, and the bright path that lies before us. I am not stating that any of these potential perils will put hospitalists out of business. However, the list below includes several risks that, if not properly mitigated, could alter our future course.

Here are 10 potential threats to the HM business model that you should keep an eye on:

1. Failure to Embrace QI

Those who fundamentally improve outcomes will write the future of medicine. Hospitalists are perfectly positioned—and expected—to do this. I believe most hospital CEOs think this is part of the contract: funding for quality. A failure to live up to our end of the bargain puts us at great risk. If your group isn’t able to demonstrate measurable improvements in processes and clinical outcomes, then you are at risk of losing hospital funding. As the economy recedes further and hospital reimbursement is more closely tied to quality, this will quickly move beyond a potential threat to a reality.

2. Lack of New Data to Support the HM Model

A corollary of No. 1 is our ability to show how we work. This burden, by and large, falls to my academic colleagues. After a rash of early studies showed the benefits of the hospitalist model, more recent data has been less convincing. This doesn’t mean we aren’t improving outcomes; rather, it means we aren’t always measuring and proving it. HM must get past the easy-to-measure endpoints, such as length-of-stay reduction and cost savings, to more meaningful endpoints, such as readmission rates, mortality, and clinical improvements. Ultimately, HM depends on robust, published data that clearly illustrate our benefit to hospitals and patients. Anything short of that intensifies the pressure to achieve No. 1.

3. Decreased Admissions

Our mother ship is under fire. Each wound our hospitals suffer is a wound to us. Erosion of hospital margins likely will translate to decreased levels of support. Nearly 40% of hospitals are experiencing a decrease in admissions. Coupled with economy-induced increases in the number of uninsured patients, this looms as a major threat to our future stability.

4. Elective Procedures

Thirty-one percent of hospitals have witnessed a decrease in lucrative, elective procedures. It began with the rise of procedural centers (e.g., surgery, gastroenterology, radiology) and is being exacerbated by the wheezing U.S. economy. Each 1% increase in unemployment results in roughly 2.5 million Americans losing their employer-provided health benefits. That means fewer elective procedures, which directly threatens the profitability of HM groups who depend on co-management revenue.

5. Recruitment

For years, HM has battled a workforce shortage, which has stifled growth and pushed providers to the verge of exhaustion. This problem persists despite offers of lucrative salaries, significant free time, and specialty status. The continuing workforce shortage should serve as a call to arms to improve recruitment into the field. An inability to increase the flow of providers will limit growth and tax the hospitalists we have in place. Ultimately, we will retard our progress toward achieving the improved outcomes articulated in No. 1.

6. Retention

We must address burnout and career satisfaction issues. Although exact numbers are tough to come by, it’s clear that many hospitalists are exhausted and overworked. This should not come as a surprise, considering we are a rapidly growing field constantly tasked with seeing more patients and solving all of a hospital’s problems. However, an inability to keep our current workforce sated and in HM jobs will amplify the workforce shortage.

7. PCPs Return

One interesting theory is that the floundering economy could prompt primary-care physicians (PCPs), whose hospital exodus we backfilled, to return to inpatient care in order to supplement their income. This isn’t likely to happen unless outpatient providers see such a drop in business that they cannot field a large-enough insured panel of patients to make ends meet. The possibility of PCPs seeing insured inpatients and leaving hospitalists with a largely uninsured population would be a game-changer. In the face of a large PCP shortage, however, this seems an unlikely scenario.

8. PCP Payment Reform

It is more likely our primary-care colleagues will get an ever-so-deserved pay raise. This is central to the proposed medical-home model and a key point of many healthcare reform plans. To stay competitive, hospitalists might also see a resultant pay increase. Anything short of this could further strain HM recruitment, as working hospitalists and new grads might migrate back toward primary-care jobs.

9. Bundling

It’s too early to know the effects of the proposed bundling of physician and hospital payments into one fee, which would compensate both hospitals and physicians. On the one hand, it could be a boon, as HM efficiency could be rewarded in ways not currently allowed. On the other hand, if hospitals continue to struggle financially and we are completely dependent upon bundled payments for our revenue, it could be a financial calamity.

10. Healthcare Reform

Without a clear sense of President Obama’s plans for healthcare reform, it’s tough to predict the future. We could try to paint numerous rosy scenarios that derive from a plan that includes a universal payor, improved access, and increased technology. However, it’s possible this reform would hamstring our efforts through reduced reimbursement, increased regulation, and cumbersome federal mandates.

Final Thought

I believe HM is strong and will overcome future threats. But it pays to consider and mitigate the hazards we might confront. Still, after much deliberation, I just cannot conceive of a reasonable scenario that results in a future without hospitalists.

Then again, Henry Ford probably felt the same about cars. 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.

In the aftermath of the recent shuttering of Colorado’s oldest newspaper, The Rocky Mountain News, a couple of colleagues and I were discussing how unlikely it seemed just a few months ago that this could happen. It wasn’t long until we made the theoretical leap to what it would take for our hospitalist group to go out of business. Of course, this seems highly unlikely, but then again, the closing of a 150-year-old metropolitan newspaper seemed a preposterous proposition.

In the course of this discussion, we conjured myriad internal or external factors that could adversely affect our program. Although this was a tangential, lunchtime discussion, it did reverberate against the tuning fork of a faltering U.S. economy, especially regarding the financial sector and the automotive industry.

With that as a frame, I thought I’d take a dip into Paranoia Pond and look at potential threats to the HM model. Let me start by saying that I believe—deeply—in the hospitalist movement, the strides we’ve made, and the bright path that lies before us. I am not stating that any of these potential perils will put hospitalists out of business. However, the list below includes several risks that, if not properly mitigated, could alter our future course.

Here are 10 potential threats to the HM business model that you should keep an eye on:

1. Failure to Embrace QI

Those who fundamentally improve outcomes will write the future of medicine. Hospitalists are perfectly positioned—and expected—to do this. I believe most hospital CEOs think this is part of the contract: funding for quality. A failure to live up to our end of the bargain puts us at great risk. If your group isn’t able to demonstrate measurable improvements in processes and clinical outcomes, then you are at risk of losing hospital funding. As the economy recedes further and hospital reimbursement is more closely tied to quality, this will quickly move beyond a potential threat to a reality.

2. Lack of New Data to Support the HM Model

A corollary of No. 1 is our ability to show how we work. This burden, by and large, falls to my academic colleagues. After a rash of early studies showed the benefits of the hospitalist model, more recent data has been less convincing. This doesn’t mean we aren’t improving outcomes; rather, it means we aren’t always measuring and proving it. HM must get past the easy-to-measure endpoints, such as length-of-stay reduction and cost savings, to more meaningful endpoints, such as readmission rates, mortality, and clinical improvements. Ultimately, HM depends on robust, published data that clearly illustrate our benefit to hospitals and patients. Anything short of that intensifies the pressure to achieve No. 1.

3. Decreased Admissions

Our mother ship is under fire. Each wound our hospitals suffer is a wound to us. Erosion of hospital margins likely will translate to decreased levels of support. Nearly 40% of hospitals are experiencing a decrease in admissions. Coupled with economy-induced increases in the number of uninsured patients, this looms as a major threat to our future stability.

4. Elective Procedures

Thirty-one percent of hospitals have witnessed a decrease in lucrative, elective procedures. It began with the rise of procedural centers (e.g., surgery, gastroenterology, radiology) and is being exacerbated by the wheezing U.S. economy. Each 1% increase in unemployment results in roughly 2.5 million Americans losing their employer-provided health benefits. That means fewer elective procedures, which directly threatens the profitability of HM groups who depend on co-management revenue.

5. Recruitment

For years, HM has battled a workforce shortage, which has stifled growth and pushed providers to the verge of exhaustion. This problem persists despite offers of lucrative salaries, significant free time, and specialty status. The continuing workforce shortage should serve as a call to arms to improve recruitment into the field. An inability to increase the flow of providers will limit growth and tax the hospitalists we have in place. Ultimately, we will retard our progress toward achieving the improved outcomes articulated in No. 1.

6. Retention

We must address burnout and career satisfaction issues. Although exact numbers are tough to come by, it’s clear that many hospitalists are exhausted and overworked. This should not come as a surprise, considering we are a rapidly growing field constantly tasked with seeing more patients and solving all of a hospital’s problems. However, an inability to keep our current workforce sated and in HM jobs will amplify the workforce shortage.

7. PCPs Return

One interesting theory is that the floundering economy could prompt primary-care physicians (PCPs), whose hospital exodus we backfilled, to return to inpatient care in order to supplement their income. This isn’t likely to happen unless outpatient providers see such a drop in business that they cannot field a large-enough insured panel of patients to make ends meet. The possibility of PCPs seeing insured inpatients and leaving hospitalists with a largely uninsured population would be a game-changer. In the face of a large PCP shortage, however, this seems an unlikely scenario.

8. PCP Payment Reform

It is more likely our primary-care colleagues will get an ever-so-deserved pay raise. This is central to the proposed medical-home model and a key point of many healthcare reform plans. To stay competitive, hospitalists might also see a resultant pay increase. Anything short of this could further strain HM recruitment, as working hospitalists and new grads might migrate back toward primary-care jobs.

9. Bundling

It’s too early to know the effects of the proposed bundling of physician and hospital payments into one fee, which would compensate both hospitals and physicians. On the one hand, it could be a boon, as HM efficiency could be rewarded in ways not currently allowed. On the other hand, if hospitals continue to struggle financially and we are completely dependent upon bundled payments for our revenue, it could be a financial calamity.

10. Healthcare Reform

Without a clear sense of President Obama’s plans for healthcare reform, it’s tough to predict the future. We could try to paint numerous rosy scenarios that derive from a plan that includes a universal payor, improved access, and increased technology. However, it’s possible this reform would hamstring our efforts through reduced reimbursement, increased regulation, and cumbersome federal mandates.

Final Thought

I believe HM is strong and will overcome future threats. But it pays to consider and mitigate the hazards we might confront. Still, after much deliberation, I just cannot conceive of a reasonable scenario that results in a future without hospitalists.

Then again, Henry Ford probably felt the same about cars. 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.

In the aftermath of the recent shuttering of Colorado’s oldest newspaper, The Rocky Mountain News, a couple of colleagues and I were discussing how unlikely it seemed just a few months ago that this could happen. It wasn’t long until we made the theoretical leap to what it would take for our hospitalist group to go out of business. Of course, this seems highly unlikely, but then again, the closing of a 150-year-old metropolitan newspaper seemed a preposterous proposition.

In the course of this discussion, we conjured myriad internal or external factors that could adversely affect our program. Although this was a tangential, lunchtime discussion, it did reverberate against the tuning fork of a faltering U.S. economy, especially regarding the financial sector and the automotive industry.

With that as a frame, I thought I’d take a dip into Paranoia Pond and look at potential threats to the HM model. Let me start by saying that I believe—deeply—in the hospitalist movement, the strides we’ve made, and the bright path that lies before us. I am not stating that any of these potential perils will put hospitalists out of business. However, the list below includes several risks that, if not properly mitigated, could alter our future course.

Here are 10 potential threats to the HM business model that you should keep an eye on:

1. Failure to Embrace QI

Those who fundamentally improve outcomes will write the future of medicine. Hospitalists are perfectly positioned—and expected—to do this. I believe most hospital CEOs think this is part of the contract: funding for quality. A failure to live up to our end of the bargain puts us at great risk. If your group isn’t able to demonstrate measurable improvements in processes and clinical outcomes, then you are at risk of losing hospital funding. As the economy recedes further and hospital reimbursement is more closely tied to quality, this will quickly move beyond a potential threat to a reality.

2. Lack of New Data to Support the HM Model

A corollary of No. 1 is our ability to show how we work. This burden, by and large, falls to my academic colleagues. After a rash of early studies showed the benefits of the hospitalist model, more recent data has been less convincing. This doesn’t mean we aren’t improving outcomes; rather, it means we aren’t always measuring and proving it. HM must get past the easy-to-measure endpoints, such as length-of-stay reduction and cost savings, to more meaningful endpoints, such as readmission rates, mortality, and clinical improvements. Ultimately, HM depends on robust, published data that clearly illustrate our benefit to hospitals and patients. Anything short of that intensifies the pressure to achieve No. 1.

3. Decreased Admissions

Our mother ship is under fire. Each wound our hospitals suffer is a wound to us. Erosion of hospital margins likely will translate to decreased levels of support. Nearly 40% of hospitals are experiencing a decrease in admissions. Coupled with economy-induced increases in the number of uninsured patients, this looms as a major threat to our future stability.

4. Elective Procedures

Thirty-one percent of hospitals have witnessed a decrease in lucrative, elective procedures. It began with the rise of procedural centers (e.g., surgery, gastroenterology, radiology) and is being exacerbated by the wheezing U.S. economy. Each 1% increase in unemployment results in roughly 2.5 million Americans losing their employer-provided health benefits. That means fewer elective procedures, which directly threatens the profitability of HM groups who depend on co-management revenue.

5. Recruitment

For years, HM has battled a workforce shortage, which has stifled growth and pushed providers to the verge of exhaustion. This problem persists despite offers of lucrative salaries, significant free time, and specialty status. The continuing workforce shortage should serve as a call to arms to improve recruitment into the field. An inability to increase the flow of providers will limit growth and tax the hospitalists we have in place. Ultimately, we will retard our progress toward achieving the improved outcomes articulated in No. 1.

6. Retention

We must address burnout and career satisfaction issues. Although exact numbers are tough to come by, it’s clear that many hospitalists are exhausted and overworked. This should not come as a surprise, considering we are a rapidly growing field constantly tasked with seeing more patients and solving all of a hospital’s problems. However, an inability to keep our current workforce sated and in HM jobs will amplify the workforce shortage.

7. PCPs Return

One interesting theory is that the floundering economy could prompt primary-care physicians (PCPs), whose hospital exodus we backfilled, to return to inpatient care in order to supplement their income. This isn’t likely to happen unless outpatient providers see such a drop in business that they cannot field a large-enough insured panel of patients to make ends meet. The possibility of PCPs seeing insured inpatients and leaving hospitalists with a largely uninsured population would be a game-changer. In the face of a large PCP shortage, however, this seems an unlikely scenario.

8. PCP Payment Reform

It is more likely our primary-care colleagues will get an ever-so-deserved pay raise. This is central to the proposed medical-home model and a key point of many healthcare reform plans. To stay competitive, hospitalists might also see a resultant pay increase. Anything short of this could further strain HM recruitment, as working hospitalists and new grads might migrate back toward primary-care jobs.

9. Bundling

It’s too early to know the effects of the proposed bundling of physician and hospital payments into one fee, which would compensate both hospitals and physicians. On the one hand, it could be a boon, as HM efficiency could be rewarded in ways not currently allowed. On the other hand, if hospitals continue to struggle financially and we are completely dependent upon bundled payments for our revenue, it could be a financial calamity.

10. Healthcare Reform

Without a clear sense of President Obama’s plans for healthcare reform, it’s tough to predict the future. We could try to paint numerous rosy scenarios that derive from a plan that includes a universal payor, improved access, and increased technology. However, it’s possible this reform would hamstring our efforts through reduced reimbursement, increased regulation, and cumbersome federal mandates.

Final Thought

I believe HM is strong and will overcome future threats. But it pays to consider and mitigate the hazards we might confront. Still, after much deliberation, I just cannot conceive of a reasonable scenario that results in a future without hospitalists.

Then again, Henry Ford probably felt the same about cars. 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.

Let’s begin with a couple of clinical questions:

Scenario One: You are discharging a 70-year-old man admitted five days earlier with community-acquired pneumonia (CAP). He has diabetes, class II heart failure, hyperlipidemia, and hypertension. He can perform daily activities, is off oxygen, and is doing well on oral antibiotics. His heart failure and blood pressure are under control, but his finger-stick blood sugars are consistently high (140-190 mg/dL) throughout his stay. You discharge him on his outpatient medication regimen. His next scheduled follow-up appointment is in four weeks.

When would you have him see his primary-care provider?

a. In two days;

b. In one week;

c. In two weeks; or

d. In four weeks.

Getty Images

Scenario Two: You admit a 70-year-old diabetic woman with atypical chest pain. She has described her pain, which is localized under her left breast, as “burning.” It occurred at rest and did not change with activity or eating. It improved about two hours after receiving an antacid. Her EKG and three troponins are normal. Her LDL cholesterol is 125 mg/dL. She is a former smoker and her blood pressure is controlled through use of lisinopril.

What do you do?

a. Order an exercise stress test;

b. Order a dobutamine stress echo;

c. Refer the patient to cardiology; or

d. Discharge the patient to home and have her follow up if she has further symptoms.

Answers:

Scenario One: We don’t know.

Scenario Two: We don’t know.

Healthcare Rationing?

Within hours of President Obama’s signing of the new economic stimulus package, I received an e-mail from my dad, who had read online that the new legislation would result in healthcare rationing. Having followed this issue relatively closely, I was puzzled by how the stimulus plan’s direct impact on healthcare—$87 billion for Medicaid, $25 billion for extension of COBRA medical insurance, $10 billion for the National Institutes of Health (NIH), nearly $20 billion for information technology infrastructure, and $1 billion for comparative effectiveness research (CER)—could be interpreted as the rationing of healthcare.

A quick peek at the Internet revealed the answer. A handful of bloggers clearly were interpreting the combination of Obama’s pledge to reduce healthcare costs and the billion-dollar appropriation for CER to mean the government would use the results of this research to limit care based on cost-effectiveness. In other words, a bureaucrat would decide if an elderly patient would receive a hip replacement based on whether it made fiscal sense.

So is healthcare rationing Obama’s solution to healthcare reform?

More Equals Less

There is great variability in the care provided throughout the U.S. There are well-known disparities—within age, race, and sex, for example—but there are also less apparent disparities. Medicare beneficiaries matched for severity of illness receive vastly different care based solely upon where they live. In 2003, per capita healthcare spending was $5,278, $5,661, and $11,350 for patients living in Portland, Oregon; Seattle; and Miami, respectively. That equates to about $125,000 additional lifetime healthcare costs for a 65-year-old treated in Miami compared with the same 65-year-old in Portland.1

And what does the Miamian get for the added cost? The results are surprisingly counterintuitive. It turns out that chronically ill elderly patients treated in more-resource-intense parts of the country do not have improved survival, quality of life, or access to care compared with those in less-resource-intense parts of the country. In fact, across most of these variables, the outcomes appear worse the more we do.2

Discover What Works

The focus in medicine has been to improve outcomes and control costs through the application of evidence-based medicine. The idea is that we can improve outcomes if everyone would just follow the clinical guidelines for an individual disease state. This has become the primary focus of pay for performance and the Joint Commission’s mandates on quality indicators, such as early antibiotics in pneumonia care.

This is sound thinking, until you realize that the vast majority of the decisions we have no definitive answer. For example, BMJ Clinical Evidence estimates that of the 2,500 treatments used for a variety of clinical problems, only 36% of them were deemed “beneficial” or “likely to be beneficial,” while 46% were of unknown benefit.3 In the absence of evidence, we are forced to use our clinical judgment, a surprisingly scary proposition when affordable, high-quality care is the goal.

This clinical judgment is what policymakers refer to as discretionary decision-making. The problem is that there is great variability in what experienced, prudent physicians judge to be appropriate. Recently, 1,275 physicians were asked about their decision-making around clinical scenarios with variable levels of evidential support. When asked when they would recommend a routine follow-up visit for a patient with well-controlled hypertension, 47% of physicians in high-resource-use areas (e.g., Miami), compared with 9% of physicians in low-resource-use areas (e.g., Portland), would recommend followup within three months compared with after three months. Management of an elderly clinic patient with new-onset chest pain was met with similar levels of variability in cardiac testing, referral to cardiology, and admission to the hospital between the higher- and lower-resource areas.

Those results contrasted with the consistent use across all spending groups for relatively proven modalities, such as mammographic screening in patients 50 to 70 years old.4 When the definitive answer isn’t available, we are left to use our clinical judgment, which often results in overuse of resources without benefit, and possibly harm.

We need to augment our focus on adherence to current guidelines with the discovery necessary to develop future guidelines. This requires that we move toward better information about what works and what doesn’t.

Enter the Obama administration’s commitment of significant resources to NIH research and comparative effectiveness research. The former allows for continued discovery of new technologies, while the latter informs clinicians about which technologies work the best for a particular clinical disease state.

Coordinating Fragmented Care

As hospitalists, our daily to-do lists are riddled with the consequences of fragmented care. We spend hours trying to track down primary-care physicians, finding test results from outside facilities, and coordinating complex care with multiple providers across multiple continuums. This results in inefficient and costly hospitalist systems, repetition of expensive tests, and overall worse patient outcomes. Thus, the stimulus bill’s push will be to build information technology (IT) infrastructure, such as electronic medical records, with the goal of making safer, more efficient systems that improve outcomes while cutting costs.

While the devil will be in the details—and with medical IT, the details can be daunting—I think this is a wise investment in our future.

We must get healthcare costs under control and improve the quality of care. There are myriad thoughts and proposals on how to accomplish this. The new administration is betting that discovery and technology will provide the answer to what to do with an acute-chest-pain patient and, in turn, the brewing healthcare crisis in America. That doesn’t sound like healthcare rationing to me, Dad. 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.

References

1. Wennberg DE, Fisher ES, Skinner JS, Bronner KK. Extending the PFP agenda, part 2: How Medicare can reduce waste and improve the care of the chronically ill. Health Affairs. 2007;26:1575-1585.

2. Fischer ES, Wennberg, JE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-298.

3. How much do we know? British Medical Journal Web site. Available at: http://clinical evidence.bmj.com/ceweb/about/knowledge.jsp. Accessed Feb. 24, 2009.

4. Sirovich B, Gallahger PM, Wennberg DE, Fisher ES. Discretionary decision-making by primary care physicians and the cost of U.S. healthcare. Health Affairs. 2008;27:813-823.

Let’s begin with a couple of clinical questions:

Scenario One: You are discharging a 70-year-old man admitted five days earlier with community-acquired pneumonia (CAP). He has diabetes, class II heart failure, hyperlipidemia, and hypertension. He can perform daily activities, is off oxygen, and is doing well on oral antibiotics. His heart failure and blood pressure are under control, but his finger-stick blood sugars are consistently high (140-190 mg/dL) throughout his stay. You discharge him on his outpatient medication regimen. His next scheduled follow-up appointment is in four weeks.

When would you have him see his primary-care provider?

a. In two days;

b. In one week;

c. In two weeks; or

d. In four weeks.

Getty Images

Scenario Two: You admit a 70-year-old diabetic woman with atypical chest pain. She has described her pain, which is localized under her left breast, as “burning.” It occurred at rest and did not change with activity or eating. It improved about two hours after receiving an antacid. Her EKG and three troponins are normal. Her LDL cholesterol is 125 mg/dL. She is a former smoker and her blood pressure is controlled through use of lisinopril.

What do you do?

a. Order an exercise stress test;

b. Order a dobutamine stress echo;

c. Refer the patient to cardiology; or

d. Discharge the patient to home and have her follow up if she has further symptoms.

Answers:

Scenario One: We don’t know.

Scenario Two: We don’t know.

Healthcare Rationing?

Within hours of President Obama’s signing of the new economic stimulus package, I received an e-mail from my dad, who had read online that the new legislation would result in healthcare rationing. Having followed this issue relatively closely, I was puzzled by how the stimulus plan’s direct impact on healthcare—$87 billion for Medicaid, $25 billion for extension of COBRA medical insurance, $10 billion for the National Institutes of Health (NIH), nearly $20 billion for information technology infrastructure, and $1 billion for comparative effectiveness research (CER)—could be interpreted as the rationing of healthcare.

A quick peek at the Internet revealed the answer. A handful of bloggers clearly were interpreting the combination of Obama’s pledge to reduce healthcare costs and the billion-dollar appropriation for CER to mean the government would use the results of this research to limit care based on cost-effectiveness. In other words, a bureaucrat would decide if an elderly patient would receive a hip replacement based on whether it made fiscal sense.

So is healthcare rationing Obama’s solution to healthcare reform?

More Equals Less

There is great variability in the care provided throughout the U.S. There are well-known disparities—within age, race, and sex, for example—but there are also less apparent disparities. Medicare beneficiaries matched for severity of illness receive vastly different care based solely upon where they live. In 2003, per capita healthcare spending was $5,278, $5,661, and $11,350 for patients living in Portland, Oregon; Seattle; and Miami, respectively. That equates to about $125,000 additional lifetime healthcare costs for a 65-year-old treated in Miami compared with the same 65-year-old in Portland.1

And what does the Miamian get for the added cost? The results are surprisingly counterintuitive. It turns out that chronically ill elderly patients treated in more-resource-intense parts of the country do not have improved survival, quality of life, or access to care compared with those in less-resource-intense parts of the country. In fact, across most of these variables, the outcomes appear worse the more we do.2

Discover What Works

The focus in medicine has been to improve outcomes and control costs through the application of evidence-based medicine. The idea is that we can improve outcomes if everyone would just follow the clinical guidelines for an individual disease state. This has become the primary focus of pay for performance and the Joint Commission’s mandates on quality indicators, such as early antibiotics in pneumonia care.

This is sound thinking, until you realize that the vast majority of the decisions we have no definitive answer. For example, BMJ Clinical Evidence estimates that of the 2,500 treatments used for a variety of clinical problems, only 36% of them were deemed “beneficial” or “likely to be beneficial,” while 46% were of unknown benefit.3 In the absence of evidence, we are forced to use our clinical judgment, a surprisingly scary proposition when affordable, high-quality care is the goal.

This clinical judgment is what policymakers refer to as discretionary decision-making. The problem is that there is great variability in what experienced, prudent physicians judge to be appropriate. Recently, 1,275 physicians were asked about their decision-making around clinical scenarios with variable levels of evidential support. When asked when they would recommend a routine follow-up visit for a patient with well-controlled hypertension, 47% of physicians in high-resource-use areas (e.g., Miami), compared with 9% of physicians in low-resource-use areas (e.g., Portland), would recommend followup within three months compared with after three months. Management of an elderly clinic patient with new-onset chest pain was met with similar levels of variability in cardiac testing, referral to cardiology, and admission to the hospital between the higher- and lower-resource areas.

Those results contrasted with the consistent use across all spending groups for relatively proven modalities, such as mammographic screening in patients 50 to 70 years old.4 When the definitive answer isn’t available, we are left to use our clinical judgment, which often results in overuse of resources without benefit, and possibly harm.

We need to augment our focus on adherence to current guidelines with the discovery necessary to develop future guidelines. This requires that we move toward better information about what works and what doesn’t.

Enter the Obama administration’s commitment of significant resources to NIH research and comparative effectiveness research. The former allows for continued discovery of new technologies, while the latter informs clinicians about which technologies work the best for a particular clinical disease state.

Coordinating Fragmented Care

As hospitalists, our daily to-do lists are riddled with the consequences of fragmented care. We spend hours trying to track down primary-care physicians, finding test results from outside facilities, and coordinating complex care with multiple providers across multiple continuums. This results in inefficient and costly hospitalist systems, repetition of expensive tests, and overall worse patient outcomes. Thus, the stimulus bill’s push will be to build information technology (IT) infrastructure, such as electronic medical records, with the goal of making safer, more efficient systems that improve outcomes while cutting costs.

While the devil will be in the details—and with medical IT, the details can be daunting—I think this is a wise investment in our future.

We must get healthcare costs under control and improve the quality of care. There are myriad thoughts and proposals on how to accomplish this. The new administration is betting that discovery and technology will provide the answer to what to do with an acute-chest-pain patient and, in turn, the brewing healthcare crisis in America. That doesn’t sound like healthcare rationing to me, Dad. 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.

References

1. Wennberg DE, Fisher ES, Skinner JS, Bronner KK. Extending the PFP agenda, part 2: How Medicare can reduce waste and improve the care of the chronically ill. Health Affairs. 2007;26:1575-1585.

2. Fischer ES, Wennberg, JE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-298.

3. How much do we know? British Medical Journal Web site. Available at: http://clinical evidence.bmj.com/ceweb/about/knowledge.jsp. Accessed Feb. 24, 2009.

4. Sirovich B, Gallahger PM, Wennberg DE, Fisher ES. Discretionary decision-making by primary care physicians and the cost of U.S. healthcare. Health Affairs. 2008;27:813-823.

Let’s begin with a couple of clinical questions:

Scenario One: You are discharging a 70-year-old man admitted five days earlier with community-acquired pneumonia (CAP). He has diabetes, class II heart failure, hyperlipidemia, and hypertension. He can perform daily activities, is off oxygen, and is doing well on oral antibiotics. His heart failure and blood pressure are under control, but his finger-stick blood sugars are consistently high (140-190 mg/dL) throughout his stay. You discharge him on his outpatient medication regimen. His next scheduled follow-up appointment is in four weeks.

When would you have him see his primary-care provider?

a. In two days;

b. In one week;

c. In two weeks; or

d. In four weeks.

Getty Images

Scenario Two: You admit a 70-year-old diabetic woman with atypical chest pain. She has described her pain, which is localized under her left breast, as “burning.” It occurred at rest and did not change with activity or eating. It improved about two hours after receiving an antacid. Her EKG and three troponins are normal. Her LDL cholesterol is 125 mg/dL. She is a former smoker and her blood pressure is controlled through use of lisinopril.

What do you do?

a. Order an exercise stress test;

b. Order a dobutamine stress echo;

c. Refer the patient to cardiology; or

d. Discharge the patient to home and have her follow up if she has further symptoms.

Answers:

Scenario One: We don’t know.

Scenario Two: We don’t know.

Healthcare Rationing?

Within hours of President Obama’s signing of the new economic stimulus package, I received an e-mail from my dad, who had read online that the new legislation would result in healthcare rationing. Having followed this issue relatively closely, I was puzzled by how the stimulus plan’s direct impact on healthcare—$87 billion for Medicaid, $25 billion for extension of COBRA medical insurance, $10 billion for the National Institutes of Health (NIH), nearly $20 billion for information technology infrastructure, and $1 billion for comparative effectiveness research (CER)—could be interpreted as the rationing of healthcare.

A quick peek at the Internet revealed the answer. A handful of bloggers clearly were interpreting the combination of Obama’s pledge to reduce healthcare costs and the billion-dollar appropriation for CER to mean the government would use the results of this research to limit care based on cost-effectiveness. In other words, a bureaucrat would decide if an elderly patient would receive a hip replacement based on whether it made fiscal sense.

So is healthcare rationing Obama’s solution to healthcare reform?

More Equals Less

There is great variability in the care provided throughout the U.S. There are well-known disparities—within age, race, and sex, for example—but there are also less apparent disparities. Medicare beneficiaries matched for severity of illness receive vastly different care based solely upon where they live. In 2003, per capita healthcare spending was $5,278, $5,661, and $11,350 for patients living in Portland, Oregon; Seattle; and Miami, respectively. That equates to about $125,000 additional lifetime healthcare costs for a 65-year-old treated in Miami compared with the same 65-year-old in Portland.1

And what does the Miamian get for the added cost? The results are surprisingly counterintuitive. It turns out that chronically ill elderly patients treated in more-resource-intense parts of the country do not have improved survival, quality of life, or access to care compared with those in less-resource-intense parts of the country. In fact, across most of these variables, the outcomes appear worse the more we do.2

Discover What Works

The focus in medicine has been to improve outcomes and control costs through the application of evidence-based medicine. The idea is that we can improve outcomes if everyone would just follow the clinical guidelines for an individual disease state. This has become the primary focus of pay for performance and the Joint Commission’s mandates on quality indicators, such as early antibiotics in pneumonia care.

This is sound thinking, until you realize that the vast majority of the decisions we have no definitive answer. For example, BMJ Clinical Evidence estimates that of the 2,500 treatments used for a variety of clinical problems, only 36% of them were deemed “beneficial” or “likely to be beneficial,” while 46% were of unknown benefit.3 In the absence of evidence, we are forced to use our clinical judgment, a surprisingly scary proposition when affordable, high-quality care is the goal.

This clinical judgment is what policymakers refer to as discretionary decision-making. The problem is that there is great variability in what experienced, prudent physicians judge to be appropriate. Recently, 1,275 physicians were asked about their decision-making around clinical scenarios with variable levels of evidential support. When asked when they would recommend a routine follow-up visit for a patient with well-controlled hypertension, 47% of physicians in high-resource-use areas (e.g., Miami), compared with 9% of physicians in low-resource-use areas (e.g., Portland), would recommend followup within three months compared with after three months. Management of an elderly clinic patient with new-onset chest pain was met with similar levels of variability in cardiac testing, referral to cardiology, and admission to the hospital between the higher- and lower-resource areas.

Those results contrasted with the consistent use across all spending groups for relatively proven modalities, such as mammographic screening in patients 50 to 70 years old.4 When the definitive answer isn’t available, we are left to use our clinical judgment, which often results in overuse of resources without benefit, and possibly harm.

We need to augment our focus on adherence to current guidelines with the discovery necessary to develop future guidelines. This requires that we move toward better information about what works and what doesn’t.

Enter the Obama administration’s commitment of significant resources to NIH research and comparative effectiveness research. The former allows for continued discovery of new technologies, while the latter informs clinicians about which technologies work the best for a particular clinical disease state.

Coordinating Fragmented Care

As hospitalists, our daily to-do lists are riddled with the consequences of fragmented care. We spend hours trying to track down primary-care physicians, finding test results from outside facilities, and coordinating complex care with multiple providers across multiple continuums. This results in inefficient and costly hospitalist systems, repetition of expensive tests, and overall worse patient outcomes. Thus, the stimulus bill’s push will be to build information technology (IT) infrastructure, such as electronic medical records, with the goal of making safer, more efficient systems that improve outcomes while cutting costs.

While the devil will be in the details—and with medical IT, the details can be daunting—I think this is a wise investment in our future.

We must get healthcare costs under control and improve the quality of care. There are myriad thoughts and proposals on how to accomplish this. The new administration is betting that discovery and technology will provide the answer to what to do with an acute-chest-pain patient and, in turn, the brewing healthcare crisis in America. That doesn’t sound like healthcare rationing to me, Dad. 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.

References

1. Wennberg DE, Fisher ES, Skinner JS, Bronner KK. Extending the PFP agenda, part 2: How Medicare can reduce waste and improve the care of the chronically ill. Health Affairs. 2007;26:1575-1585.

2. Fischer ES, Wennberg, JE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-298.

3. How much do we know? British Medical Journal Web site. Available at: http://clinical evidence.bmj.com/ceweb/about/knowledge.jsp. Accessed Feb. 24, 2009.

4. Sirovich B, Gallahger PM, Wennberg DE, Fisher ES. Discretionary decision-making by primary care physicians and the cost of U.S. healthcare. Health Affairs. 2008;27:813-823.

As the New Year dawns I, like many Americans, am afraid.

Over the past year we’ve experienced a global financial meltdown, a deepening recession, rampant home foreclosures, Humpty Dumpty-like nest eggs, and the once-proud American auto industry gasping for breath. All of this is balanced against the hope that springs from the election of the first black President, who promises “change we can believe in.”

Hospitals are in growing financial straits and those in charge are deeply concerned, if not downright scared. In some ways, this is hard to imagine. Most hospitals reported outstanding, if not record, profits for the 2007 and 2008 fiscal years. However, change is afoot. Hospital admissions are down at nearly a third of hospitals, with a similar number of hospitals reporting declines in lucrative elective procedures. Additionally, recession-induced layoffs have resulted in a sharp rise in the proportion of uncompensated care that, when coupled with mushrooming debt and tighter credit, is propelling many hospitals into the red.

As a result, Moody’s, the credit-rating giant, has reported a rash of hospital credit downgrades. In October and November alone, Moody’s downgraded 18 hospitals and upgraded only one. At the same time, Fitch, another credit agency, downgraded the entire hospital sector from “stable” to “negative.” Although the subject of credit downgrades is somewhat abstract for many practicing physicians, the upshot is that it will be more expensive to finance hospital debt.

Coming on the heels of the largest hospital-building boom in American history, billions of dollars of debt present a very thorny fiscal rose. When this coalesces with less hospital utilization, more nonpaying patients, and potential decreases in federal reimbursement, it represents a financial crunch of catastrophic proportions.

Thus, it is no surprise our hospital administrators are on edge.

Hospitalist Impact

Enter me, the director of a money-losing service line, into an executive-filled room to propose expansion of hospital support for my hospitalist program. With average hospital support running a tad under $100,000 per hospitalist nationally, and overall support of about a million dollars per hospitalist group a year, any request for expansion will be scrutinized with a jaundiced eye.

In my experience, growing our hospitalist group was welcomed when the hospital’s coffers were bulging, the ED was overcrowded, and hospital beds were expanding. Granted, we had robust data showing our presence cut the average length of stay, increased throughput, and improved patient satisfaction—in other words, we paid for ourselves through enhanced efficiencies and cost savings. Still, the current economic realities dictate an unprecedented level of cost-consciousness and fiscal diligence. The result is my negotiations with my hospital administration have intensified, with an increased examination of expansion proposals, infrastructure development, and salary support.

Opportunity Abounds

So what are we—or I, in this case—to do? As I look at the potential of a prolonged recession, I am convinced this situation offers us a profound opportunity. Let’s face it: The hospital medicine boom was born out of opportunity. Early hospitalists took advantage of the opportunity to staff unassigned patients in the ED, backfill the migration of primary care doctors out of the hospital, enhance DRG reimbursements, reduce length of stay, and improve patient, staff, and subspecialist satisfaction because of our ability and willingness to staff inpatients around the clock.

In the coming years, we will again be offered opportunities, although they likely will come disguised as challenges. Some will choose to ignore these challenges in the hope they just go away, preferring instead to fear the unknown. Others will turn this fear into action and prosper. Opportunities will center on our ability to enhance patient outcomes and experiences. As federal dollars dry up and more and more Americans become uninsured or underinsured, hospitals will be pushed to augment the level of service and care they provide.

On one hand, payors have determined (appropriately so) that they want quality over quantity, and those who can provide superior outcomes will be better reimbursed. With thinning margins, hospitals will look for effector arms to engage the type of process improvement necessary to improve outcomes and, subsequently, revenue. We should not cower from this challenge, rather, embrace it; this is our chance to shine. Hospitalists are better positioned, better than any other medical group, to re-engineer the processes of care required to improve the quality of hospital care.

At the same time, our customers—the patients—likely will be footing more of the bill. As such, this new breed of healthcare consumer will expect a higher level of service than previously delivered. Again, hospitals that can provide five-star service will be better positioned to capture this coveted but ever-shrinking cohort of paying patients. This again positions hospitalists well. In my hospital, our group cares for just over 25% of all hospitalized patients, about 5,500 admissions per year.

Many hospitalist groups have a reach well beyond that, perhaps approaching 75%. Consider the type of bargaining power a hospitalist group could have by systematically showing that your work improves patient satisfaction, retention, and referral.

Measurement Is Crucial

Which brings me to my final point: As the economy tightens further, we will feel a heretofore-unrealized pressure to document our benefit. If we cannot document the fact our work improves processes, reduces length of stay, enhances the quality of patient care, and increases patient satisfaction, then we run the risk of being a glaringly large, negative budgetary line item waiting to be slashed.

With resolutions in the air, I resolve to work closely with my group and our hospital to document our value, prove our worth, do it better. Indubitably, this will meet with resistance, as some will advocate turning a blind eye, afraid of the challenges we might encounter. I, however, am going to choose to embrace these opportunities by fearing the known, rather than the unknown.

I have no doubt an honest assessment of the work we do and the value we provide might be anxiety provoking. It will force us to evaluate our care in ways we fear, measure our outcomes in ways we fear, push ourselves to improve in ways we fear.

In a word, change. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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.

As the New Year dawns I, like many Americans, am afraid.

Over the past year we’ve experienced a global financial meltdown, a deepening recession, rampant home foreclosures, Humpty Dumpty-like nest eggs, and the once-proud American auto industry gasping for breath. All of this is balanced against the hope that springs from the election of the first black President, who promises “change we can believe in.”

Hospitals are in growing financial straits and those in charge are deeply concerned, if not downright scared. In some ways, this is hard to imagine. Most hospitals reported outstanding, if not record, profits for the 2007 and 2008 fiscal years. However, change is afoot. Hospital admissions are down at nearly a third of hospitals, with a similar number of hospitals reporting declines in lucrative elective procedures. Additionally, recession-induced layoffs have resulted in a sharp rise in the proportion of uncompensated care that, when coupled with mushrooming debt and tighter credit, is propelling many hospitals into the red.

As a result, Moody’s, the credit-rating giant, has reported a rash of hospital credit downgrades. In October and November alone, Moody’s downgraded 18 hospitals and upgraded only one. At the same time, Fitch, another credit agency, downgraded the entire hospital sector from “stable” to “negative.” Although the subject of credit downgrades is somewhat abstract for many practicing physicians, the upshot is that it will be more expensive to finance hospital debt.

Coming on the heels of the largest hospital-building boom in American history, billions of dollars of debt present a very thorny fiscal rose. When this coalesces with less hospital utilization, more nonpaying patients, and potential decreases in federal reimbursement, it represents a financial crunch of catastrophic proportions.

Thus, it is no surprise our hospital administrators are on edge.

Hospitalist Impact

Enter me, the director of a money-losing service line, into an executive-filled room to propose expansion of hospital support for my hospitalist program. With average hospital support running a tad under $100,000 per hospitalist nationally, and overall support of about a million dollars per hospitalist group a year, any request for expansion will be scrutinized with a jaundiced eye.

In my experience, growing our hospitalist group was welcomed when the hospital’s coffers were bulging, the ED was overcrowded, and hospital beds were expanding. Granted, we had robust data showing our presence cut the average length of stay, increased throughput, and improved patient satisfaction—in other words, we paid for ourselves through enhanced efficiencies and cost savings. Still, the current economic realities dictate an unprecedented level of cost-consciousness and fiscal diligence. The result is my negotiations with my hospital administration have intensified, with an increased examination of expansion proposals, infrastructure development, and salary support.

Opportunity Abounds

So what are we—or I, in this case—to do? As I look at the potential of a prolonged recession, I am convinced this situation offers us a profound opportunity. Let’s face it: The hospital medicine boom was born out of opportunity. Early hospitalists took advantage of the opportunity to staff unassigned patients in the ED, backfill the migration of primary care doctors out of the hospital, enhance DRG reimbursements, reduce length of stay, and improve patient, staff, and subspecialist satisfaction because of our ability and willingness to staff inpatients around the clock.

In the coming years, we will again be offered opportunities, although they likely will come disguised as challenges. Some will choose to ignore these challenges in the hope they just go away, preferring instead to fear the unknown. Others will turn this fear into action and prosper. Opportunities will center on our ability to enhance patient outcomes and experiences. As federal dollars dry up and more and more Americans become uninsured or underinsured, hospitals will be pushed to augment the level of service and care they provide.

On one hand, payors have determined (appropriately so) that they want quality over quantity, and those who can provide superior outcomes will be better reimbursed. With thinning margins, hospitals will look for effector arms to engage the type of process improvement necessary to improve outcomes and, subsequently, revenue. We should not cower from this challenge, rather, embrace it; this is our chance to shine. Hospitalists are better positioned, better than any other medical group, to re-engineer the processes of care required to improve the quality of hospital care.

At the same time, our customers—the patients—likely will be footing more of the bill. As such, this new breed of healthcare consumer will expect a higher level of service than previously delivered. Again, hospitals that can provide five-star service will be better positioned to capture this coveted but ever-shrinking cohort of paying patients. This again positions hospitalists well. In my hospital, our group cares for just over 25% of all hospitalized patients, about 5,500 admissions per year.

Many hospitalist groups have a reach well beyond that, perhaps approaching 75%. Consider the type of bargaining power a hospitalist group could have by systematically showing that your work improves patient satisfaction, retention, and referral.

Measurement Is Crucial

Which brings me to my final point: As the economy tightens further, we will feel a heretofore-unrealized pressure to document our benefit. If we cannot document the fact our work improves processes, reduces length of stay, enhances the quality of patient care, and increases patient satisfaction, then we run the risk of being a glaringly large, negative budgetary line item waiting to be slashed.

With resolutions in the air, I resolve to work closely with my group and our hospital to document our value, prove our worth, do it better. Indubitably, this will meet with resistance, as some will advocate turning a blind eye, afraid of the challenges we might encounter. I, however, am going to choose to embrace these opportunities by fearing the known, rather than the unknown.

I have no doubt an honest assessment of the work we do and the value we provide might be anxiety provoking. It will force us to evaluate our care in ways we fear, measure our outcomes in ways we fear, push ourselves to improve in ways we fear.

In a word, change. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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.

As the New Year dawns I, like many Americans, am afraid.

Over the past year we’ve experienced a global financial meltdown, a deepening recession, rampant home foreclosures, Humpty Dumpty-like nest eggs, and the once-proud American auto industry gasping for breath. All of this is balanced against the hope that springs from the election of the first black President, who promises “change we can believe in.”

Hospitals are in growing financial straits and those in charge are deeply concerned, if not downright scared. In some ways, this is hard to imagine. Most hospitals reported outstanding, if not record, profits for the 2007 and 2008 fiscal years. However, change is afoot. Hospital admissions are down at nearly a third of hospitals, with a similar number of hospitals reporting declines in lucrative elective procedures. Additionally, recession-induced layoffs have resulted in a sharp rise in the proportion of uncompensated care that, when coupled with mushrooming debt and tighter credit, is propelling many hospitals into the red.

As a result, Moody’s, the credit-rating giant, has reported a rash of hospital credit downgrades. In October and November alone, Moody’s downgraded 18 hospitals and upgraded only one. At the same time, Fitch, another credit agency, downgraded the entire hospital sector from “stable” to “negative.” Although the subject of credit downgrades is somewhat abstract for many practicing physicians, the upshot is that it will be more expensive to finance hospital debt.

Coming on the heels of the largest hospital-building boom in American history, billions of dollars of debt present a very thorny fiscal rose. When this coalesces with less hospital utilization, more nonpaying patients, and potential decreases in federal reimbursement, it represents a financial crunch of catastrophic proportions.

Thus, it is no surprise our hospital administrators are on edge.

Hospitalist Impact

Enter me, the director of a money-losing service line, into an executive-filled room to propose expansion of hospital support for my hospitalist program. With average hospital support running a tad under $100,000 per hospitalist nationally, and overall support of about a million dollars per hospitalist group a year, any request for expansion will be scrutinized with a jaundiced eye.

In my experience, growing our hospitalist group was welcomed when the hospital’s coffers were bulging, the ED was overcrowded, and hospital beds were expanding. Granted, we had robust data showing our presence cut the average length of stay, increased throughput, and improved patient satisfaction—in other words, we paid for ourselves through enhanced efficiencies and cost savings. Still, the current economic realities dictate an unprecedented level of cost-consciousness and fiscal diligence. The result is my negotiations with my hospital administration have intensified, with an increased examination of expansion proposals, infrastructure development, and salary support.

Opportunity Abounds

So what are we—or I, in this case—to do? As I look at the potential of a prolonged recession, I am convinced this situation offers us a profound opportunity. Let’s face it: The hospital medicine boom was born out of opportunity. Early hospitalists took advantage of the opportunity to staff unassigned patients in the ED, backfill the migration of primary care doctors out of the hospital, enhance DRG reimbursements, reduce length of stay, and improve patient, staff, and subspecialist satisfaction because of our ability and willingness to staff inpatients around the clock.

In the coming years, we will again be offered opportunities, although they likely will come disguised as challenges. Some will choose to ignore these challenges in the hope they just go away, preferring instead to fear the unknown. Others will turn this fear into action and prosper. Opportunities will center on our ability to enhance patient outcomes and experiences. As federal dollars dry up and more and more Americans become uninsured or underinsured, hospitals will be pushed to augment the level of service and care they provide.

On one hand, payors have determined (appropriately so) that they want quality over quantity, and those who can provide superior outcomes will be better reimbursed. With thinning margins, hospitals will look for effector arms to engage the type of process improvement necessary to improve outcomes and, subsequently, revenue. We should not cower from this challenge, rather, embrace it; this is our chance to shine. Hospitalists are better positioned, better than any other medical group, to re-engineer the processes of care required to improve the quality of hospital care.

At the same time, our customers—the patients—likely will be footing more of the bill. As such, this new breed of healthcare consumer will expect a higher level of service than previously delivered. Again, hospitals that can provide five-star service will be better positioned to capture this coveted but ever-shrinking cohort of paying patients. This again positions hospitalists well. In my hospital, our group cares for just over 25% of all hospitalized patients, about 5,500 admissions per year.

Many hospitalist groups have a reach well beyond that, perhaps approaching 75%. Consider the type of bargaining power a hospitalist group could have by systematically showing that your work improves patient satisfaction, retention, and referral.

Measurement Is Crucial

Which brings me to my final point: As the economy tightens further, we will feel a heretofore-unrealized pressure to document our benefit. If we cannot document the fact our work improves processes, reduces length of stay, enhances the quality of patient care, and increases patient satisfaction, then we run the risk of being a glaringly large, negative budgetary line item waiting to be slashed.

With resolutions in the air, I resolve to work closely with my group and our hospital to document our value, prove our worth, do it better. Indubitably, this will meet with resistance, as some will advocate turning a blind eye, afraid of the challenges we might encounter. I, however, am going to choose to embrace these opportunities by fearing the known, rather than the unknown.

I have no doubt an honest assessment of the work we do and the value we provide might be anxiety provoking. It will force us to evaluate our care in ways we fear, measure our outcomes in ways we fear, push ourselves to improve in ways we fear.

In a word, change. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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.

I read the ads.” “The what?” I replied, dumbfounded.

“The ads.”

“Not ‘In the Literature,’ ‘Key Clinical Questions,’ the cover stories, John Nelson’s practice management column?”

“No,” “no,” “no” and “no” were the responses.

Encasing my slightly bruised ego behind a facade of curiosity, I inquired of my friend who directs a large community hospitalist practice why the first thing he reads in The Hospitalist are the advertisements.

“Because I need to know what the competition is offering, so that I can keep my docs,” my friend explained.

“With that it was clearer than ever that we have a shortage of hospitalists. Let’s take a look at some numbers.”

Numbers Part I

The good news is there are close to 20,000 hospitalists in the U.S. This meteoric rise occurred in 11 years; something emergency medicine took 20 years to accomplish. It is commonly assumed the mature hospital medicine field will grow to 30,000 providers. More grandiose estimates place the top estimate as high as 70,000.

Numbers Part II

The concerning news is the number of adults 65 and older is expected to double by 2030. This demographic accounts for nearly 50% of all hospital admissions, and thus heralds an onslaught of growth in hospital medicine. Workforce models predict a physician shortfall of 200,000 by the year 2020.1

Numbers Part III

The frightening news is the number of U.S. medical school graduates matching into internal medicine (IM) residency programs has dropped from 3,884 in 1985 to 2,660 in 2007.1 Only 22% of graduating U.S. medical school students chooses to match in IM and only 55% of IM residency positions are filled by U.S. medical school graduates.2 Nearly 60% of IM graduates choose subspecialist careers, with only 8% choosing hospitalist careers.3

Runaway Train

The U.S. is likely to witness an astronomic growth in the supply of hospitalized patients. Fewer students are choosing IM, with the majority of these opting for subspecialty careers. Hospital medicine faces an ever growing workforce shortage that has the potential to cripple the field.

I often wonder if hospital medicine is developing too fast. Our haste to grow and take on new business can, at times, lead us astray. To be sure, some of this growth is thrust on us by external forces, such as the mass exodus of primary care doctors out of the hospital and hospital executives’ eagerness to tap the resource efficiency of the hospitalist model. However, we cannot allow our foremost mission—improving patient experiences and outcomes—to be lost in a landslide of growth that outstrips our staffing.

Limit Growth

To that end, I think one very logical solution to this pending workforce shortage is to limit growth. Take a breather and let the supply catch up with the demand before growing further. The skeptic will say this is not possible, but recall that hospitalized patients received care for hundreds of years prior to hospitalists. Ask yourself how much of the work you do could be done by another physician group. A recent study I was part of reported more than 22% of a community hospitalist’s workload consists of orthopedic, neurological, and general surgical diagnoses.4 Our study design was unable to account for patients previously cared for by medical sub-specialists, such as cardiologists and gastroenterologists, but I suspect the number is large, as well.

Although a 22% decrease in volume across the board would not solve all of our problems, it would be a solid start. Consider this the next time a surgical or medical subspecialty group requests you care for their patients. It may be a poor business move to refuse this work, but perhaps you can build a collaborative, long-term plan that allows you to better care for the patient obligations you have today while incrementally caring for their patients as your group matures.

Higher, Faster, Farther

Another method to tackle the hospitalist shortage is to see more patients with the same amount of providers. Doing this requires more than just increasing the patient numerator as you hold the provider denominator steady. Rather, it requires real systems changes to enhance provider efficiency. A significant amount of a hospitalists’ daily workload consists of non-patient care activity, such as searching for charts, waiting for consultants to call back and scheduling follow-up appointments. The challenge to future hospitalists will be to tame these inefficiencies by developing more streamlined hospital systems and care processes.

This may include hiring assistants, rounding staff, and/or mid-level providers to incrementally increase the number of patients the group can see per physician. These are not without risks and barriers, and many groups currently are wrestling with how to best utilize and integrate these providers in a cost-effective manner. However, I think it is likely these components will provide the future scaffolding to allow groups to care for ever increasing numbers of patients.

Prime the Pump

Perhaps, most importantly, we need to develop ways to attract more medical students and residents to hospitalist careers. This will be challenging and falls squarely to my academic hospital medicine colleagues, as our learners see us as the yardstick for a hospitalist career. Unfortunately, the growth trend in academic hospital medicine has been in non-teaching or uncovered services. These jobs often are an academic necropolis, with the providers routinely being overworked and devalued by their institution.

As a result, academic hospitalist positions often times are filled by recent residency graduates awaiting a fellowship. These “R4” or “pretending” positions provide very rickety underpinnings from which to build the foundation of hospital medicine. Don’t for an instant think this goes unnoticed by our student and resident colleagues who choose their career based on the role models they see early in their training.

It is essential hospital medicine develops truly sustainable academic careers replete with opportunities to fulfill the inimitable tenets of academic medicine—teaching and scholarly work. For these reasons, SHM has partnered with the Society of General Internal Medicine and the Association of Chiefs in General Internal Medicine to develop the Academic Hospitalist Academy. The four-day academy premiers next fall. Its goal is to enable academic hospitalists to become exceptional educators, institutional leaders, and successful scholars—the exact type of role models that will attract the best and the brightest to the field of hospital medicine for generations to come. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300:1154-1156,1164.

2. Hauer KE, Fagan MJ, Kernan W, Mintz M, Durning SJ. Internal medicine clerkship directors’ perceptions about student interest in internal medicine careers. J Gen Intern Med. 2008;1101-1104.

3. McDonald FS, West CP, Popkave C, Kolars JC. Educational debt and reported career plans among internal medicine residents. Ann Inter Med. 2008;149:416-420.

4. Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community based hospitalist practice: A call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727-729.

I read the ads.” “The what?” I replied, dumbfounded.

“The ads.”

“Not ‘In the Literature,’ ‘Key Clinical Questions,’ the cover stories, John Nelson’s practice management column?”

“No,” “no,” “no” and “no” were the responses.

Encasing my slightly bruised ego behind a facade of curiosity, I inquired of my friend who directs a large community hospitalist practice why the first thing he reads in The Hospitalist are the advertisements.

“Because I need to know what the competition is offering, so that I can keep my docs,” my friend explained.

“With that it was clearer than ever that we have a shortage of hospitalists. Let’s take a look at some numbers.”

Numbers Part I

The good news is there are close to 20,000 hospitalists in the U.S. This meteoric rise occurred in 11 years; something emergency medicine took 20 years to accomplish. It is commonly assumed the mature hospital medicine field will grow to 30,000 providers. More grandiose estimates place the top estimate as high as 70,000.

Numbers Part II

The concerning news is the number of adults 65 and older is expected to double by 2030. This demographic accounts for nearly 50% of all hospital admissions, and thus heralds an onslaught of growth in hospital medicine. Workforce models predict a physician shortfall of 200,000 by the year 2020.1

Numbers Part III

The frightening news is the number of U.S. medical school graduates matching into internal medicine (IM) residency programs has dropped from 3,884 in 1985 to 2,660 in 2007.1 Only 22% of graduating U.S. medical school students chooses to match in IM and only 55% of IM residency positions are filled by U.S. medical school graduates.2 Nearly 60% of IM graduates choose subspecialist careers, with only 8% choosing hospitalist careers.3

Runaway Train

The U.S. is likely to witness an astronomic growth in the supply of hospitalized patients. Fewer students are choosing IM, with the majority of these opting for subspecialty careers. Hospital medicine faces an ever growing workforce shortage that has the potential to cripple the field.

I often wonder if hospital medicine is developing too fast. Our haste to grow and take on new business can, at times, lead us astray. To be sure, some of this growth is thrust on us by external forces, such as the mass exodus of primary care doctors out of the hospital and hospital executives’ eagerness to tap the resource efficiency of the hospitalist model. However, we cannot allow our foremost mission—improving patient experiences and outcomes—to be lost in a landslide of growth that outstrips our staffing.

Limit Growth

To that end, I think one very logical solution to this pending workforce shortage is to limit growth. Take a breather and let the supply catch up with the demand before growing further. The skeptic will say this is not possible, but recall that hospitalized patients received care for hundreds of years prior to hospitalists. Ask yourself how much of the work you do could be done by another physician group. A recent study I was part of reported more than 22% of a community hospitalist’s workload consists of orthopedic, neurological, and general surgical diagnoses.4 Our study design was unable to account for patients previously cared for by medical sub-specialists, such as cardiologists and gastroenterologists, but I suspect the number is large, as well.

Although a 22% decrease in volume across the board would not solve all of our problems, it would be a solid start. Consider this the next time a surgical or medical subspecialty group requests you care for their patients. It may be a poor business move to refuse this work, but perhaps you can build a collaborative, long-term plan that allows you to better care for the patient obligations you have today while incrementally caring for their patients as your group matures.

Higher, Faster, Farther

Another method to tackle the hospitalist shortage is to see more patients with the same amount of providers. Doing this requires more than just increasing the patient numerator as you hold the provider denominator steady. Rather, it requires real systems changes to enhance provider efficiency. A significant amount of a hospitalists’ daily workload consists of non-patient care activity, such as searching for charts, waiting for consultants to call back and scheduling follow-up appointments. The challenge to future hospitalists will be to tame these inefficiencies by developing more streamlined hospital systems and care processes.

This may include hiring assistants, rounding staff, and/or mid-level providers to incrementally increase the number of patients the group can see per physician. These are not without risks and barriers, and many groups currently are wrestling with how to best utilize and integrate these providers in a cost-effective manner. However, I think it is likely these components will provide the future scaffolding to allow groups to care for ever increasing numbers of patients.

Prime the Pump

Perhaps, most importantly, we need to develop ways to attract more medical students and residents to hospitalist careers. This will be challenging and falls squarely to my academic hospital medicine colleagues, as our learners see us as the yardstick for a hospitalist career. Unfortunately, the growth trend in academic hospital medicine has been in non-teaching or uncovered services. These jobs often are an academic necropolis, with the providers routinely being overworked and devalued by their institution.

As a result, academic hospitalist positions often times are filled by recent residency graduates awaiting a fellowship. These “R4” or “pretending” positions provide very rickety underpinnings from which to build the foundation of hospital medicine. Don’t for an instant think this goes unnoticed by our student and resident colleagues who choose their career based on the role models they see early in their training.

It is essential hospital medicine develops truly sustainable academic careers replete with opportunities to fulfill the inimitable tenets of academic medicine—teaching and scholarly work. For these reasons, SHM has partnered with the Society of General Internal Medicine and the Association of Chiefs in General Internal Medicine to develop the Academic Hospitalist Academy. The four-day academy premiers next fall. Its goal is to enable academic hospitalists to become exceptional educators, institutional leaders, and successful scholars—the exact type of role models that will attract the best and the brightest to the field of hospital medicine for generations to come. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300:1154-1156,1164.

2. Hauer KE, Fagan MJ, Kernan W, Mintz M, Durning SJ. Internal medicine clerkship directors’ perceptions about student interest in internal medicine careers. J Gen Intern Med. 2008;1101-1104.

3. McDonald FS, West CP, Popkave C, Kolars JC. Educational debt and reported career plans among internal medicine residents. Ann Inter Med. 2008;149:416-420.

4. Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community based hospitalist practice: A call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727-729.

I read the ads.” “The what?” I replied, dumbfounded.

“The ads.”

“Not ‘In the Literature,’ ‘Key Clinical Questions,’ the cover stories, John Nelson’s practice management column?”

“No,” “no,” “no” and “no” were the responses.

Encasing my slightly bruised ego behind a facade of curiosity, I inquired of my friend who directs a large community hospitalist practice why the first thing he reads in The Hospitalist are the advertisements.

“Because I need to know what the competition is offering, so that I can keep my docs,” my friend explained.

“With that it was clearer than ever that we have a shortage of hospitalists. Let’s take a look at some numbers.”

Numbers Part I

The good news is there are close to 20,000 hospitalists in the U.S. This meteoric rise occurred in 11 years; something emergency medicine took 20 years to accomplish. It is commonly assumed the mature hospital medicine field will grow to 30,000 providers. More grandiose estimates place the top estimate as high as 70,000.

Numbers Part II

The concerning news is the number of adults 65 and older is expected to double by 2030. This demographic accounts for nearly 50% of all hospital admissions, and thus heralds an onslaught of growth in hospital medicine. Workforce models predict a physician shortfall of 200,000 by the year 2020.1

Numbers Part III

The frightening news is the number of U.S. medical school graduates matching into internal medicine (IM) residency programs has dropped from 3,884 in 1985 to 2,660 in 2007.1 Only 22% of graduating U.S. medical school students chooses to match in IM and only 55% of IM residency positions are filled by U.S. medical school graduates.2 Nearly 60% of IM graduates choose subspecialist careers, with only 8% choosing hospitalist careers.3

Runaway Train

The U.S. is likely to witness an astronomic growth in the supply of hospitalized patients. Fewer students are choosing IM, with the majority of these opting for subspecialty careers. Hospital medicine faces an ever growing workforce shortage that has the potential to cripple the field.

I often wonder if hospital medicine is developing too fast. Our haste to grow and take on new business can, at times, lead us astray. To be sure, some of this growth is thrust on us by external forces, such as the mass exodus of primary care doctors out of the hospital and hospital executives’ eagerness to tap the resource efficiency of the hospitalist model. However, we cannot allow our foremost mission—improving patient experiences and outcomes—to be lost in a landslide of growth that outstrips our staffing.

Limit Growth

To that end, I think one very logical solution to this pending workforce shortage is to limit growth. Take a breather and let the supply catch up with the demand before growing further. The skeptic will say this is not possible, but recall that hospitalized patients received care for hundreds of years prior to hospitalists. Ask yourself how much of the work you do could be done by another physician group. A recent study I was part of reported more than 22% of a community hospitalist’s workload consists of orthopedic, neurological, and general surgical diagnoses.4 Our study design was unable to account for patients previously cared for by medical sub-specialists, such as cardiologists and gastroenterologists, but I suspect the number is large, as well.

Although a 22% decrease in volume across the board would not solve all of our problems, it would be a solid start. Consider this the next time a surgical or medical subspecialty group requests you care for their patients. It may be a poor business move to refuse this work, but perhaps you can build a collaborative, long-term plan that allows you to better care for the patient obligations you have today while incrementally caring for their patients as your group matures.

Higher, Faster, Farther

Another method to tackle the hospitalist shortage is to see more patients with the same amount of providers. Doing this requires more than just increasing the patient numerator as you hold the provider denominator steady. Rather, it requires real systems changes to enhance provider efficiency. A significant amount of a hospitalists’ daily workload consists of non-patient care activity, such as searching for charts, waiting for consultants to call back and scheduling follow-up appointments. The challenge to future hospitalists will be to tame these inefficiencies by developing more streamlined hospital systems and care processes.

This may include hiring assistants, rounding staff, and/or mid-level providers to incrementally increase the number of patients the group can see per physician. These are not without risks and barriers, and many groups currently are wrestling with how to best utilize and integrate these providers in a cost-effective manner. However, I think it is likely these components will provide the future scaffolding to allow groups to care for ever increasing numbers of patients.

Prime the Pump

Perhaps, most importantly, we need to develop ways to attract more medical students and residents to hospitalist careers. This will be challenging and falls squarely to my academic hospital medicine colleagues, as our learners see us as the yardstick for a hospitalist career. Unfortunately, the growth trend in academic hospital medicine has been in non-teaching or uncovered services. These jobs often are an academic necropolis, with the providers routinely being overworked and devalued by their institution.

As a result, academic hospitalist positions often times are filled by recent residency graduates awaiting a fellowship. These “R4” or “pretending” positions provide very rickety underpinnings from which to build the foundation of hospital medicine. Don’t for an instant think this goes unnoticed by our student and resident colleagues who choose their career based on the role models they see early in their training.

It is essential hospital medicine develops truly sustainable academic careers replete with opportunities to fulfill the inimitable tenets of academic medicine—teaching and scholarly work. For these reasons, SHM has partnered with the Society of General Internal Medicine and the Association of Chiefs in General Internal Medicine to develop the Academic Hospitalist Academy. The four-day academy premiers next fall. Its goal is to enable academic hospitalists to become exceptional educators, institutional leaders, and successful scholars—the exact type of role models that will attract the best and the brightest to the field of hospital medicine for generations to come. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300:1154-1156,1164.

2. Hauer KE, Fagan MJ, Kernan W, Mintz M, Durning SJ. Internal medicine clerkship directors’ perceptions about student interest in internal medicine careers. J Gen Intern Med. 2008;1101-1104.

3. McDonald FS, West CP, Popkave C, Kolars JC. Educational debt and reported career plans among internal medicine residents. Ann Inter Med. 2008;149:416-420.

4. Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community based hospitalist practice: A call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727-729.

As the trail dips past the creek and the sun crests the sky, something catches the corner of my eye. I immediately sense I am in trouble; this is how my life will end, presaged by the signpost at the trailhead.

I have a friend who is convinced everyone who lives in Colorado will die in a mountain lion attack. If pushed, she may allow a soul or two to be gobbled up by a bear. But the mountain lion—a.k.a. cougar—will get the, well, lion’s share of us. To her, everyone who ventures out into the wild for a hike, mountain bike or snowshoe adventure is just biding time, simmering away in the cougar’s crock, eventual forest filet for our feral friends.

Prior to a hike, I’ll often call up her various bits of wisdom, such as never hike alone, wear a bell, bring a whistle, carry mace (both the atomized spray and the medieval warring device, I presume). All this in the name of preventing or fending off a predator’s attack. This always has struck me as a bit paranoid, especially considering only 20 deaths by mountain lions have been recorded in all of North America since 1890. Still, this friend is unwaveringly convinced mountain lions pose a real threat to life and limb. And for the time being, hiking alone, I can’t help but share her fear.

Just a quick blur; then nothing. Pupils dilating, palms moist, I slowly pivot, centering my peripheral vision on my attacker.

Phobia Management

It always struck me that there are things in life we tend to fear and things we tend to trust, and more often than not we get them confused. To be sure, mountain lion and bear attacks do happen, but are exceedingly uncommon. Ditto plane crashes. While most of us harbor at least a modicum of fear of perishing in a plane crash, it’s nearly impossible to die in such a manner. By one estimate, a modern commercial airline traveler would need to fly continuously for nearly 20,000 years to reach a 50-50 chance of death by plane crash. To put it another way, the chances of dying on your next flight are one in a many million, roughly the same as winning the lottery. People do win the lottery, but you and I probably won’t.

Reaching for my pepper spray, I am struck by the fact I don’t hike with pepper spray. But I am carrying a sizable rock—I picked it up a mile back—and I slowly turn it over in my palm preparing to crush the skull of my ambusher.

Then there are the things we should fear: cars, guns, fishing.

The average U.S. adult has about a one in 6,500 chance of dying in a car accident every year. This means you are infinitely more likely to die on the road than in the air (a one in 430,000 chance of death per annum). Also more likely to do you in are firearms, which are 17 times more likely to kill you than air travel (1 in 25,000). Oddly perilous is fishing. Statistically speaking, there is one death annually for every 1,000 fisherman. Now, growing up in northern Wisconsin I spent the bulk of my formative years in a boat with drunken fishermen. Still, I was surprised to learn fishing is so mortal. However, it turns out commercial—not recreational fishing—is the most dangerous occupation in America.

The White Elephant

Heart in torsades, I tried to recollect whether a lion attack merited I run or remain still-but-menacing. Paralyzed by indecision, I coaxed a scowl across my face, just in case it was the latter.

Then there is the thing we should all truly fear, U.S. healthcare.

As many as one in 200 individuals hospitalized in the U.S. will die from an adverse event during a hospital stay. This doesn’t include the numerous people who come into the hospital with a disease, such as pneumonia, and die of pneumonia. Rather, these are patients who come into the hospital with pneumonia and die from an anaphylactic penicillin reaction, which doctors overlooked on their allergy list or from a pulmonary embolism doctors forgot to prophylax against.

Two landmark patient safety studies, respectively, revealed 2.9% and 3.7% rates of medical error in hospitals. Moreover, in these two studies, 6.6% and 13.6% of the errors led to death, respectively. That means roughly one in 30 patients suffered a medical error with one in 10 of those errors resulting in death. Further math reveals 0.2% to 0.5% of overall hospitalized patients will die from a medical error. In other words, the patient awaiting admission orders in your emergency department right now has a 1 in 200 to 1 in 500 chance of death from an error your hospital or its staff will make. Now that’s something to really fear.

Not all of these deaths are avoidable; however, many of the nearly 100,000 annual deaths from adverse events are preventable. Furthermore, these events represent just the tip of the iceberg. Millions more errors yield mere morbid outcomes, or do not reach the level of harm, but are nonetheless noteworthy. One study found 19% of all medications administered in the hospital are given erroneously. Basically, only 80% of medications are given correctly.

Think of these numbers the next time you fly. What if the pilot’s post-takeoff announcement assured you there was an 80% chance they’d get you to the correct destination, a 96% chance you’d arrive without the pilot making a serious error, and a 99% chance you’d arrive alive. Would you fly?

Unfortunately, our patients don’t have the option to avoid our hospitals.

Resolved to fight to the death, my assassin slowly came into view. Shrouded in cover, the first thing I noticed about my predator was his eyes, yellow and foreboding as they pierced my soul.

Next, I uncovered his torso, sinewy and compact, ready to pounce.

Finally, his tail, long and tapered—wait, not long but short. Not tapered but bushy.

Just then I heard a child coming up the trail shriek with delight.

“Look mommy, a deer!” TH

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

References

1. Arizona Game and Fish Department. http://www.azgfd.gov/w_c/mtn_lion_attacks.shtml. Accessed November 3, 2008.

2. National Safety Council 2004 statistics. http://www.nsc.org/research/odds.aspx. Accessed November 3, 2008.

3. Centers for Disease Control. http://www.cdc.gov/niosh/topics/fishing/. Accessed November 3, 2008.

4. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-271.

5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;7;324:370-376.

6. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 healthcare facilities. Arch Intern Med. 2002;162:1897-1903.

As the trail dips past the creek and the sun crests the sky, something catches the corner of my eye. I immediately sense I am in trouble; this is how my life will end, presaged by the signpost at the trailhead.

I have a friend who is convinced everyone who lives in Colorado will die in a mountain lion attack. If pushed, she may allow a soul or two to be gobbled up by a bear. But the mountain lion—a.k.a. cougar—will get the, well, lion’s share of us. To her, everyone who ventures out into the wild for a hike, mountain bike or snowshoe adventure is just biding time, simmering away in the cougar’s crock, eventual forest filet for our feral friends.

Prior to a hike, I’ll often call up her various bits of wisdom, such as never hike alone, wear a bell, bring a whistle, carry mace (both the atomized spray and the medieval warring device, I presume). All this in the name of preventing or fending off a predator’s attack. This always has struck me as a bit paranoid, especially considering only 20 deaths by mountain lions have been recorded in all of North America since 1890. Still, this friend is unwaveringly convinced mountain lions pose a real threat to life and limb. And for the time being, hiking alone, I can’t help but share her fear.

Just a quick blur; then nothing. Pupils dilating, palms moist, I slowly pivot, centering my peripheral vision on my attacker.

Phobia Management

It always struck me that there are things in life we tend to fear and things we tend to trust, and more often than not we get them confused. To be sure, mountain lion and bear attacks do happen, but are exceedingly uncommon. Ditto plane crashes. While most of us harbor at least a modicum of fear of perishing in a plane crash, it’s nearly impossible to die in such a manner. By one estimate, a modern commercial airline traveler would need to fly continuously for nearly 20,000 years to reach a 50-50 chance of death by plane crash. To put it another way, the chances of dying on your next flight are one in a many million, roughly the same as winning the lottery. People do win the lottery, but you and I probably won’t.

Reaching for my pepper spray, I am struck by the fact I don’t hike with pepper spray. But I am carrying a sizable rock—I picked it up a mile back—and I slowly turn it over in my palm preparing to crush the skull of my ambusher.

Then there are the things we should fear: cars, guns, fishing.

The average U.S. adult has about a one in 6,500 chance of dying in a car accident every year. This means you are infinitely more likely to die on the road than in the air (a one in 430,000 chance of death per annum). Also more likely to do you in are firearms, which are 17 times more likely to kill you than air travel (1 in 25,000). Oddly perilous is fishing. Statistically speaking, there is one death annually for every 1,000 fisherman. Now, growing up in northern Wisconsin I spent the bulk of my formative years in a boat with drunken fishermen. Still, I was surprised to learn fishing is so mortal. However, it turns out commercial—not recreational fishing—is the most dangerous occupation in America.

The White Elephant

Heart in torsades, I tried to recollect whether a lion attack merited I run or remain still-but-menacing. Paralyzed by indecision, I coaxed a scowl across my face, just in case it was the latter.

Then there is the thing we should all truly fear, U.S. healthcare.

As many as one in 200 individuals hospitalized in the U.S. will die from an adverse event during a hospital stay. This doesn’t include the numerous people who come into the hospital with a disease, such as pneumonia, and die of pneumonia. Rather, these are patients who come into the hospital with pneumonia and die from an anaphylactic penicillin reaction, which doctors overlooked on their allergy list or from a pulmonary embolism doctors forgot to prophylax against.

Two landmark patient safety studies, respectively, revealed 2.9% and 3.7% rates of medical error in hospitals. Moreover, in these two studies, 6.6% and 13.6% of the errors led to death, respectively. That means roughly one in 30 patients suffered a medical error with one in 10 of those errors resulting in death. Further math reveals 0.2% to 0.5% of overall hospitalized patients will die from a medical error. In other words, the patient awaiting admission orders in your emergency department right now has a 1 in 200 to 1 in 500 chance of death from an error your hospital or its staff will make. Now that’s something to really fear.

Not all of these deaths are avoidable; however, many of the nearly 100,000 annual deaths from adverse events are preventable. Furthermore, these events represent just the tip of the iceberg. Millions more errors yield mere morbid outcomes, or do not reach the level of harm, but are nonetheless noteworthy. One study found 19% of all medications administered in the hospital are given erroneously. Basically, only 80% of medications are given correctly.

Think of these numbers the next time you fly. What if the pilot’s post-takeoff announcement assured you there was an 80% chance they’d get you to the correct destination, a 96% chance you’d arrive without the pilot making a serious error, and a 99% chance you’d arrive alive. Would you fly?

Unfortunately, our patients don’t have the option to avoid our hospitals.

Resolved to fight to the death, my assassin slowly came into view. Shrouded in cover, the first thing I noticed about my predator was his eyes, yellow and foreboding as they pierced my soul.

Next, I uncovered his torso, sinewy and compact, ready to pounce.

Finally, his tail, long and tapered—wait, not long but short. Not tapered but bushy.

Just then I heard a child coming up the trail shriek with delight.

“Look mommy, a deer!” TH

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

References

1. Arizona Game and Fish Department. http://www.azgfd.gov/w_c/mtn_lion_attacks.shtml. Accessed November 3, 2008.

2. National Safety Council 2004 statistics. http://www.nsc.org/research/odds.aspx. Accessed November 3, 2008.

3. Centers for Disease Control. http://www.cdc.gov/niosh/topics/fishing/. Accessed November 3, 2008.

4. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-271.

5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;7;324:370-376.

6. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 healthcare facilities. Arch Intern Med. 2002;162:1897-1903.

As the trail dips past the creek and the sun crests the sky, something catches the corner of my eye. I immediately sense I am in trouble; this is how my life will end, presaged by the signpost at the trailhead.

I have a friend who is convinced everyone who lives in Colorado will die in a mountain lion attack. If pushed, she may allow a soul or two to be gobbled up by a bear. But the mountain lion—a.k.a. cougar—will get the, well, lion’s share of us. To her, everyone who ventures out into the wild for a hike, mountain bike or snowshoe adventure is just biding time, simmering away in the cougar’s crock, eventual forest filet for our feral friends.

Prior to a hike, I’ll often call up her various bits of wisdom, such as never hike alone, wear a bell, bring a whistle, carry mace (both the atomized spray and the medieval warring device, I presume). All this in the name of preventing or fending off a predator’s attack. This always has struck me as a bit paranoid, especially considering only 20 deaths by mountain lions have been recorded in all of North America since 1890. Still, this friend is unwaveringly convinced mountain lions pose a real threat to life and limb. And for the time being, hiking alone, I can’t help but share her fear.

Just a quick blur; then nothing. Pupils dilating, palms moist, I slowly pivot, centering my peripheral vision on my attacker.

Phobia Management

It always struck me that there are things in life we tend to fear and things we tend to trust, and more often than not we get them confused. To be sure, mountain lion and bear attacks do happen, but are exceedingly uncommon. Ditto plane crashes. While most of us harbor at least a modicum of fear of perishing in a plane crash, it’s nearly impossible to die in such a manner. By one estimate, a modern commercial airline traveler would need to fly continuously for nearly 20,000 years to reach a 50-50 chance of death by plane crash. To put it another way, the chances of dying on your next flight are one in a many million, roughly the same as winning the lottery. People do win the lottery, but you and I probably won’t.

Reaching for my pepper spray, I am struck by the fact I don’t hike with pepper spray. But I am carrying a sizable rock—I picked it up a mile back—and I slowly turn it over in my palm preparing to crush the skull of my ambusher.

Then there are the things we should fear: cars, guns, fishing.

The average U.S. adult has about a one in 6,500 chance of dying in a car accident every year. This means you are infinitely more likely to die on the road than in the air (a one in 430,000 chance of death per annum). Also more likely to do you in are firearms, which are 17 times more likely to kill you than air travel (1 in 25,000). Oddly perilous is fishing. Statistically speaking, there is one death annually for every 1,000 fisherman. Now, growing up in northern Wisconsin I spent the bulk of my formative years in a boat with drunken fishermen. Still, I was surprised to learn fishing is so mortal. However, it turns out commercial—not recreational fishing—is the most dangerous occupation in America.

The White Elephant

Heart in torsades, I tried to recollect whether a lion attack merited I run or remain still-but-menacing. Paralyzed by indecision, I coaxed a scowl across my face, just in case it was the latter.

Then there is the thing we should all truly fear, U.S. healthcare.

As many as one in 200 individuals hospitalized in the U.S. will die from an adverse event during a hospital stay. This doesn’t include the numerous people who come into the hospital with a disease, such as pneumonia, and die of pneumonia. Rather, these are patients who come into the hospital with pneumonia and die from an anaphylactic penicillin reaction, which doctors overlooked on their allergy list or from a pulmonary embolism doctors forgot to prophylax against.

Two landmark patient safety studies, respectively, revealed 2.9% and 3.7% rates of medical error in hospitals. Moreover, in these two studies, 6.6% and 13.6% of the errors led to death, respectively. That means roughly one in 30 patients suffered a medical error with one in 10 of those errors resulting in death. Further math reveals 0.2% to 0.5% of overall hospitalized patients will die from a medical error. In other words, the patient awaiting admission orders in your emergency department right now has a 1 in 200 to 1 in 500 chance of death from an error your hospital or its staff will make. Now that’s something to really fear.

Not all of these deaths are avoidable; however, many of the nearly 100,000 annual deaths from adverse events are preventable. Furthermore, these events represent just the tip of the iceberg. Millions more errors yield mere morbid outcomes, or do not reach the level of harm, but are nonetheless noteworthy. One study found 19% of all medications administered in the hospital are given erroneously. Basically, only 80% of medications are given correctly.

Think of these numbers the next time you fly. What if the pilot’s post-takeoff announcement assured you there was an 80% chance they’d get you to the correct destination, a 96% chance you’d arrive without the pilot making a serious error, and a 99% chance you’d arrive alive. Would you fly?

Unfortunately, our patients don’t have the option to avoid our hospitals.

Resolved to fight to the death, my assassin slowly came into view. Shrouded in cover, the first thing I noticed about my predator was his eyes, yellow and foreboding as they pierced my soul.

Next, I uncovered his torso, sinewy and compact, ready to pounce.

Finally, his tail, long and tapered—wait, not long but short. Not tapered but bushy.

Just then I heard a child coming up the trail shriek with delight.

“Look mommy, a deer!” TH

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

References

1. Arizona Game and Fish Department. http://www.azgfd.gov/w_c/mtn_lion_attacks.shtml. Accessed November 3, 2008.

2. National Safety Council 2004 statistics. http://www.nsc.org/research/odds.aspx. Accessed November 3, 2008.

3. Centers for Disease Control. http://www.cdc.gov/niosh/topics/fishing/. Accessed November 3, 2008.

4. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-271.

5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;7;324:370-376.

6. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 healthcare facilities. Arch Intern Med. 2002;162:1897-1903.

The financial sector and Wall Street, as we know it, are gone. The carnage is breathtaking in its breadth, swiftness and finality. As a passive retirement investor, with an even more passive understanding of the world of finance, I was shocked when Bear Stearns collapsed. Then Lehman Brothers, a 158-year old investment firm failed, and Merrill Lynch narrowly avoided bankruptcy, albeit through a Bank of America buyout.

Questions swirled in my mind: How could a company like Lehman, which makes money by trading money, go bankrupt? How could they have survived the economic crises of 1873, 1929 and 1987 only to succumb in 2008? How could a company with billions of dollars in assets fail? How could an established company go from leader to loser so fast—sweeping the streets that they used to own?

If this calamity could befall presumably intelligent, highly educated, seasoned managers of Fortune 500 companies, could it happen to my company, the hospitalist group I direct? I have neither an MBA nor an undergraduate business degree; never set foot in the business school at my college. Truth be told, I don’t even balance my checkbook.

With the disclaimer that I know about as much about Wall Street’s operations as they know about mine, here are a few cautionary lessons I learned from watching this financial meltdown.

Liquidity and Reserves

It appears many of Wall Street’s problems can be traced to liquidity—that is having dollars held in reserve. Although sub-prime mortgages are at the center of this crisis, the reality is the vast majority of these loans are not in default. Instead, as big a contributor to this meltdown was the practice of lending money without liquid reserves to back those loans. Investment firms had plenty of assets, just not enough in reserves to cover a spat of delinquencies or a rush of withdrawals.

Hospitalist groups operate in similar ways, with the major difference being almost all of us lose money. In the most recent SHM Bi-Annual Survey on the State of the Hospital Medicine Movement, 85% of hospitalist groups reported an operating deficit. This means we require capital from an outside source to stay afloat. That someone, our creditor, is most often the hospital. Ninety-one percent of HM groups receive financial support from hospitals through offset agreements or an annual stipend.

Just like our Wall Street counterparts, HMGs have a ton of assets in the form of human capital, but often hold very little financial capital in reserve. So, if our investors suddenly pulled their support, the result might not be too dissimilar to what is happening on Wall Street. I’d venture a guess that very few hospitalist groups have enough money in reserve to weather a storm. Look at your balance sheet. Could your group handle a 20% cut in hospital support next year without having to lower salaries or cut hospitalists? If the answer is “no,” you probably could benefit from more reserves.

Understand Your Business

It seems so obvious, but to be successful you need a firm grasp of what you do. I have no doubt someone at Lehman understood credit derivatives, credit default swaps, and mortgage-backed securities. However, it is painfully clear they didn’t recognize all the implications of these products. For example, what would happen if a company that increasingly invested in sub-prime mortgages suddenly saw a rash of these investments go sour—namely, a rush of creditors wanting their money back—immediately? Bankruptcy, that’s what would—and did—happen.

This couldn’t happen to hospitalists, could it? Well, shockingly, 35% and 37% of hospitalist group leaders said they did not know their group’s annual professional fee revenues and expenses, respectively. It is, therefore, likely many leaders do not know the more granular data points necessary to have long-term success (i.e., payer mixes, service line profit margins, rates of quality adherence and reimbursement and denial rates). To understand the potential implications of not knowing your business, look no further than the current crisis on Wall Street.

Diversification

The old saw about not putting all your eggs in one basket seems as applicable to the credit crisis as it is to your retirement accounts. The more traditional banking institutions, such as Bank of America, appear as if they will survive in large part because they remained diversified. Although they engaged in sub-prime mortgages, they also maintained a large commercial banking operation that deposited savings and kept them in holding. The upshot? When creditors came calling, Bank of America had plenty of cash on hand.

I’m not suggesting hospitalist groups open a savings and loan, rather we diversify the services we offer to help soften potential future turmoil. I often hear from hospitalists who don’t want co-management, as it is not traditional medicine and it may subjugate them to their surgical colleagues. While the latter point is valid and must be mitigated, surgical co-management, stroke services, observation units, palliative care services, and preoperative clinics all serve as potential markets for diversification. We cannot predict how future market forces (e.g., Medicare coverage changes, payment bundling, disproportionate share cuts, etc.) will impact our practice; but we can increase our chances of future success by diversifying our business portfolio.

Although clinical diversification is important, don’t forget to grow your quality service line. I strongly believe those that can impact quality in meaningful and measurable ways will win in the end. Once the hospitalist market saturates, there will be competition and groups that have a track record for systematically improving outcomes will be the ones who continue to garner hospital funding.

I fundamentally believe in the strength of the hospitalist movement and doubt our business will ever experience the type of calamity that has ensnared the financial sector. However, it behooves us to learn from our fallen Wall Street brethren, lest we someday find ourselves sweeping the streets alongside them. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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.

The financial sector and Wall Street, as we know it, are gone. The carnage is breathtaking in its breadth, swiftness and finality. As a passive retirement investor, with an even more passive understanding of the world of finance, I was shocked when Bear Stearns collapsed. Then Lehman Brothers, a 158-year old investment firm failed, and Merrill Lynch narrowly avoided bankruptcy, albeit through a Bank of America buyout.

Questions swirled in my mind: How could a company like Lehman, which makes money by trading money, go bankrupt? How could they have survived the economic crises of 1873, 1929 and 1987 only to succumb in 2008? How could a company with billions of dollars in assets fail? How could an established company go from leader to loser so fast—sweeping the streets that they used to own?

If this calamity could befall presumably intelligent, highly educated, seasoned managers of Fortune 500 companies, could it happen to my company, the hospitalist group I direct? I have neither an MBA nor an undergraduate business degree; never set foot in the business school at my college. Truth be told, I don’t even balance my checkbook.

With the disclaimer that I know about as much about Wall Street’s operations as they know about mine, here are a few cautionary lessons I learned from watching this financial meltdown.

Liquidity and Reserves

It appears many of Wall Street’s problems can be traced to liquidity—that is having dollars held in reserve. Although sub-prime mortgages are at the center of this crisis, the reality is the vast majority of these loans are not in default. Instead, as big a contributor to this meltdown was the practice of lending money without liquid reserves to back those loans. Investment firms had plenty of assets, just not enough in reserves to cover a spat of delinquencies or a rush of withdrawals.

Hospitalist groups operate in similar ways, with the major difference being almost all of us lose money. In the most recent SHM Bi-Annual Survey on the State of the Hospital Medicine Movement, 85% of hospitalist groups reported an operating deficit. This means we require capital from an outside source to stay afloat. That someone, our creditor, is most often the hospital. Ninety-one percent of HM groups receive financial support from hospitals through offset agreements or an annual stipend.

Just like our Wall Street counterparts, HMGs have a ton of assets in the form of human capital, but often hold very little financial capital in reserve. So, if our investors suddenly pulled their support, the result might not be too dissimilar to what is happening on Wall Street. I’d venture a guess that very few hospitalist groups have enough money in reserve to weather a storm. Look at your balance sheet. Could your group handle a 20% cut in hospital support next year without having to lower salaries or cut hospitalists? If the answer is “no,” you probably could benefit from more reserves.

Understand Your Business

It seems so obvious, but to be successful you need a firm grasp of what you do. I have no doubt someone at Lehman understood credit derivatives, credit default swaps, and mortgage-backed securities. However, it is painfully clear they didn’t recognize all the implications of these products. For example, what would happen if a company that increasingly invested in sub-prime mortgages suddenly saw a rash of these investments go sour—namely, a rush of creditors wanting their money back—immediately? Bankruptcy, that’s what would—and did—happen.

This couldn’t happen to hospitalists, could it? Well, shockingly, 35% and 37% of hospitalist group leaders said they did not know their group’s annual professional fee revenues and expenses, respectively. It is, therefore, likely many leaders do not know the more granular data points necessary to have long-term success (i.e., payer mixes, service line profit margins, rates of quality adherence and reimbursement and denial rates). To understand the potential implications of not knowing your business, look no further than the current crisis on Wall Street.

Diversification

The old saw about not putting all your eggs in one basket seems as applicable to the credit crisis as it is to your retirement accounts. The more traditional banking institutions, such as Bank of America, appear as if they will survive in large part because they remained diversified. Although they engaged in sub-prime mortgages, they also maintained a large commercial banking operation that deposited savings and kept them in holding. The upshot? When creditors came calling, Bank of America had plenty of cash on hand.

I’m not suggesting hospitalist groups open a savings and loan, rather we diversify the services we offer to help soften potential future turmoil. I often hear from hospitalists who don’t want co-management, as it is not traditional medicine and it may subjugate them to their surgical colleagues. While the latter point is valid and must be mitigated, surgical co-management, stroke services, observation units, palliative care services, and preoperative clinics all serve as potential markets for diversification. We cannot predict how future market forces (e.g., Medicare coverage changes, payment bundling, disproportionate share cuts, etc.) will impact our practice; but we can increase our chances of future success by diversifying our business portfolio.

Although clinical diversification is important, don’t forget to grow your quality service line. I strongly believe those that can impact quality in meaningful and measurable ways will win in the end. Once the hospitalist market saturates, there will be competition and groups that have a track record for systematically improving outcomes will be the ones who continue to garner hospital funding.

I fundamentally believe in the strength of the hospitalist movement and doubt our business will ever experience the type of calamity that has ensnared the financial sector. However, it behooves us to learn from our fallen Wall Street brethren, lest we someday find ourselves sweeping the streets alongside them. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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.

The financial sector and Wall Street, as we know it, are gone. The carnage is breathtaking in its breadth, swiftness and finality. As a passive retirement investor, with an even more passive understanding of the world of finance, I was shocked when Bear Stearns collapsed. Then Lehman Brothers, a 158-year old investment firm failed, and Merrill Lynch narrowly avoided bankruptcy, albeit through a Bank of America buyout.

Questions swirled in my mind: How could a company like Lehman, which makes money by trading money, go bankrupt? How could they have survived the economic crises of 1873, 1929 and 1987 only to succumb in 2008? How could a company with billions of dollars in assets fail? How could an established company go from leader to loser so fast—sweeping the streets that they used to own?

If this calamity could befall presumably intelligent, highly educated, seasoned managers of Fortune 500 companies, could it happen to my company, the hospitalist group I direct? I have neither an MBA nor an undergraduate business degree; never set foot in the business school at my college. Truth be told, I don’t even balance my checkbook.

With the disclaimer that I know about as much about Wall Street’s operations as they know about mine, here are a few cautionary lessons I learned from watching this financial meltdown.

Liquidity and Reserves

It appears many of Wall Street’s problems can be traced to liquidity—that is having dollars held in reserve. Although sub-prime mortgages are at the center of this crisis, the reality is the vast majority of these loans are not in default. Instead, as big a contributor to this meltdown was the practice of lending money without liquid reserves to back those loans. Investment firms had plenty of assets, just not enough in reserves to cover a spat of delinquencies or a rush of withdrawals.

Hospitalist groups operate in similar ways, with the major difference being almost all of us lose money. In the most recent SHM Bi-Annual Survey on the State of the Hospital Medicine Movement, 85% of hospitalist groups reported an operating deficit. This means we require capital from an outside source to stay afloat. That someone, our creditor, is most often the hospital. Ninety-one percent of HM groups receive financial support from hospitals through offset agreements or an annual stipend.

Just like our Wall Street counterparts, HMGs have a ton of assets in the form of human capital, but often hold very little financial capital in reserve. So, if our investors suddenly pulled their support, the result might not be too dissimilar to what is happening on Wall Street. I’d venture a guess that very few hospitalist groups have enough money in reserve to weather a storm. Look at your balance sheet. Could your group handle a 20% cut in hospital support next year without having to lower salaries or cut hospitalists? If the answer is “no,” you probably could benefit from more reserves.

Understand Your Business

It seems so obvious, but to be successful you need a firm grasp of what you do. I have no doubt someone at Lehman understood credit derivatives, credit default swaps, and mortgage-backed securities. However, it is painfully clear they didn’t recognize all the implications of these products. For example, what would happen if a company that increasingly invested in sub-prime mortgages suddenly saw a rash of these investments go sour—namely, a rush of creditors wanting their money back—immediately? Bankruptcy, that’s what would—and did—happen.

This couldn’t happen to hospitalists, could it? Well, shockingly, 35% and 37% of hospitalist group leaders said they did not know their group’s annual professional fee revenues and expenses, respectively. It is, therefore, likely many leaders do not know the more granular data points necessary to have long-term success (i.e., payer mixes, service line profit margins, rates of quality adherence and reimbursement and denial rates). To understand the potential implications of not knowing your business, look no further than the current crisis on Wall Street.

Diversification

The old saw about not putting all your eggs in one basket seems as applicable to the credit crisis as it is to your retirement accounts. The more traditional banking institutions, such as Bank of America, appear as if they will survive in large part because they remained diversified. Although they engaged in sub-prime mortgages, they also maintained a large commercial banking operation that deposited savings and kept them in holding. The upshot? When creditors came calling, Bank of America had plenty of cash on hand.

I’m not suggesting hospitalist groups open a savings and loan, rather we diversify the services we offer to help soften potential future turmoil. I often hear from hospitalists who don’t want co-management, as it is not traditional medicine and it may subjugate them to their surgical colleagues. While the latter point is valid and must be mitigated, surgical co-management, stroke services, observation units, palliative care services, and preoperative clinics all serve as potential markets for diversification. We cannot predict how future market forces (e.g., Medicare coverage changes, payment bundling, disproportionate share cuts, etc.) will impact our practice; but we can increase our chances of future success by diversifying our business portfolio.

Although clinical diversification is important, don’t forget to grow your quality service line. I strongly believe those that can impact quality in meaningful and measurable ways will win in the end. Once the hospitalist market saturates, there will be competition and groups that have a track record for systematically improving outcomes will be the ones who continue to garner hospital funding.

I fundamentally believe in the strength of the hospitalist movement and doubt our business will ever experience the type of calamity that has ensnared the financial sector. However, it behooves us to learn from our fallen Wall Street brethren, lest we someday find ourselves sweeping the streets alongside them. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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.

How did I get myself into this and, more importantly, how could I get out of it?

I could act like I had inadvertently shown up at the wrong room, “so sorry to barge in, I’ll be on my way now.” Or, I could fake an important page that would require me to attend to an “emergency.” Or, I could just tell the group, “look, as much as I’d love to meet with you all for two straight days, I really have more important things to do with my time.”

Problem was I had been part of the decision to call this meeting in the first place. What was I thinking?

For years I’ve sat on a capacity management committee that met frequently and tackled various projects, such as reducing length of stay, discharging patients earlier in the day, and improving the discharge process—all of which fell under the rubric of efficiently moving patients through the system so we could create space for more patients. This not only makes good business, sense but also is good for our patients who benefit from getting out of the hospital earlier and back to the recuperative comfort of their homes.

The committee had met for hours on end, discussing new methods to tackle old problems. What if…we developed a follow-up clinic that could see patients back shortly after discharge, had a discharge nurse whose only responsibility was to discharge patients, had a lounge that could hold discharged patients waiting for a ride, and so on.

Hour after hour, meeting after meeting, we searched for the elusive Rosetta stone that would unlock the mystery of the timely discharge. We often implemented a large intervention, then met again only to find that our glorious idea came up short. We’d scratch our heads, find someone to pin the blame on for these shortcomings and move on to the next doomed project. Ideas were waning, patience was frayed and morale was at an all-time low.

At our wits end we decided to get thinner, reduce waste, make cars.

Ok, not literally make cars but to use the methodology of the Toyota Production System (TPS) to remove waste, to get lean. Sounded like a good idea until I settled into my hardback chair for the meeting that first morning. I quickly was filled with the ominous dread that only results from mixing consultants, a trough full of meeting-issue scrambled eggs congealing over a Sterno flame, and a roomful of sleepy-eyed participants. Sprinkle in a two-day agenda and we had all the ingredients for a scalding caldron of tedium, bubbling over with boredom.

Then something interesting happened.

I became interested.

Our consultants initiated our journey by discussing the basis of lean Toyota production—the theory of Kaizen, or “change (Kai) for the good (Zen).” The essence of the process included multi-day continuous sessions (yikes) utilizing a cross-functional team consisting of leadership and front-line staff from all hospital disciplines—from doctors to nurses to transport to janitorial staff. It also focused on fast, continuous, experimental change.

Then something interesting happened.

We left the room.

A meeting that didn’t meet? What was this strange Japanese system? Well it turns out that another key tenet of the TPS is “gemba,” meaning “shop floor.” The idea is to spend as much time as possible observing the actual processes, out on the shop floor, not in the board room. So, rather than wallowing away in a meeting discussing what we thought the problem was, we actually went to see what the problem was.

We split into teams and were instructed to observe various parts of the discharge process. Specifically, we were charged with differentiating between processes that add value—things people would pay for—and processes that did not add value—things people wouldn’t pay for.

It is estimated that up to 40% of a nurse’s day is spent “nursing” an inefficient system. Any hospitalist who has spent time holding on the phone, chasing down a CT scan report, or scouring the documentation vortex that mysteriously confiscate charts only to just as mysteriously cough them back up 20 minutes later, knows how much time is wasted in a typical day.

Then something interesting happened.

We realized broken systems, not people, were to blame for most of our problems.

After several hours of observation the teams reconvened and discussed their findings. We discovered that efficiently discharging patients earlier in the day could not be accomplished simply by imploring the physicians to write the orders earlier in the day, an intervention that had been continuously failing since I was an intern 12 years earlier.

In fact, the committee discovered there wasn’t a single unifying solution to this problem. Rather, hundreds of gremlins were dwelling within the recesses of our hospital, together gumming up the system. In just one day of observation, our teams identified 70 different contused processes causing our system to hemorrhage inefficiency.

Then something interesting happened.

It was time to go home; our first day was complete.

The second day of Kaizen centered on “tests of change” that could be implemented immediately and then studied for effect. Each group proffered ideas to solve identified problems and then began implementing these changes, taking time to alter the intervention whenever a better method was uncovered.

For example, an inability to timely locate wheelchairs was slowing the transport of discharged patients out of the hospital. This problem was resolved by designating two wheelchairs for this activity alone; a lack of communication with the patient, family and nursing about the timing of discharge was addressed by placing a whiteboard in the room that physicians would use to catalogue the benchmarks for discharge as well as an anticipated discharge date and time; delays in social work planning were tackled by a five-minute “lightning round” between the doctors and the social workers at 8 a.m. every morning; redundant paperwork required to discharge a patient was consolidated.

On and on it went, every additional step exorcising another discharge gremlin.

Then something interesting happened.

We realized the key to efficiency lie not in changing one or two giant unruly processes rather in effecting multiple very small changes.

No one individual or system was to blame for delayed discharges. Years of patches, work-arounds and waste had accumulated in our system like the layers of paint covering the grime on the walls of an old house. We would need to slowly—but surely—chip away at these layers if we were going to achieve our goals. None of us were convinced these immediate changes would solve our problem, but for the first time we felt empowered to make the kind of changes that would lead us to real systems improvement.

Then something interesting happened.

The second day ended. We’d made a ton of progress and I didn’t even need to invoke that fake emergency page. TH

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

How did I get myself into this and, more importantly, how could I get out of it?

I could act like I had inadvertently shown up at the wrong room, “so sorry to barge in, I’ll be on my way now.” Or, I could fake an important page that would require me to attend to an “emergency.” Or, I could just tell the group, “look, as much as I’d love to meet with you all for two straight days, I really have more important things to do with my time.”

Problem was I had been part of the decision to call this meeting in the first place. What was I thinking?

For years I’ve sat on a capacity management committee that met frequently and tackled various projects, such as reducing length of stay, discharging patients earlier in the day, and improving the discharge process—all of which fell under the rubric of efficiently moving patients through the system so we could create space for more patients. This not only makes good business, sense but also is good for our patients who benefit from getting out of the hospital earlier and back to the recuperative comfort of their homes.

The committee had met for hours on end, discussing new methods to tackle old problems. What if…we developed a follow-up clinic that could see patients back shortly after discharge, had a discharge nurse whose only responsibility was to discharge patients, had a lounge that could hold discharged patients waiting for a ride, and so on.

Hour after hour, meeting after meeting, we searched for the elusive Rosetta stone that would unlock the mystery of the timely discharge. We often implemented a large intervention, then met again only to find that our glorious idea came up short. We’d scratch our heads, find someone to pin the blame on for these shortcomings and move on to the next doomed project. Ideas were waning, patience was frayed and morale was at an all-time low.

At our wits end we decided to get thinner, reduce waste, make cars.

Ok, not literally make cars but to use the methodology of the Toyota Production System (TPS) to remove waste, to get lean. Sounded like a good idea until I settled into my hardback chair for the meeting that first morning. I quickly was filled with the ominous dread that only results from mixing consultants, a trough full of meeting-issue scrambled eggs congealing over a Sterno flame, and a roomful of sleepy-eyed participants. Sprinkle in a two-day agenda and we had all the ingredients for a scalding caldron of tedium, bubbling over with boredom.

Then something interesting happened.

I became interested.

Our consultants initiated our journey by discussing the basis of lean Toyota production—the theory of Kaizen, or “change (Kai) for the good (Zen).” The essence of the process included multi-day continuous sessions (yikes) utilizing a cross-functional team consisting of leadership and front-line staff from all hospital disciplines—from doctors to nurses to transport to janitorial staff. It also focused on fast, continuous, experimental change.

Then something interesting happened.

We left the room.

A meeting that didn’t meet? What was this strange Japanese system? Well it turns out that another key tenet of the TPS is “gemba,” meaning “shop floor.” The idea is to spend as much time as possible observing the actual processes, out on the shop floor, not in the board room. So, rather than wallowing away in a meeting discussing what we thought the problem was, we actually went to see what the problem was.

We split into teams and were instructed to observe various parts of the discharge process. Specifically, we were charged with differentiating between processes that add value—things people would pay for—and processes that did not add value—things people wouldn’t pay for.

It is estimated that up to 40% of a nurse’s day is spent “nursing” an inefficient system. Any hospitalist who has spent time holding on the phone, chasing down a CT scan report, or scouring the documentation vortex that mysteriously confiscate charts only to just as mysteriously cough them back up 20 minutes later, knows how much time is wasted in a typical day.

Then something interesting happened.

We realized broken systems, not people, were to blame for most of our problems.

After several hours of observation the teams reconvened and discussed their findings. We discovered that efficiently discharging patients earlier in the day could not be accomplished simply by imploring the physicians to write the orders earlier in the day, an intervention that had been continuously failing since I was an intern 12 years earlier.

In fact, the committee discovered there wasn’t a single unifying solution to this problem. Rather, hundreds of gremlins were dwelling within the recesses of our hospital, together gumming up the system. In just one day of observation, our teams identified 70 different contused processes causing our system to hemorrhage inefficiency.

Then something interesting happened.

It was time to go home; our first day was complete.

The second day of Kaizen centered on “tests of change” that could be implemented immediately and then studied for effect. Each group proffered ideas to solve identified problems and then began implementing these changes, taking time to alter the intervention whenever a better method was uncovered.

For example, an inability to timely locate wheelchairs was slowing the transport of discharged patients out of the hospital. This problem was resolved by designating two wheelchairs for this activity alone; a lack of communication with the patient, family and nursing about the timing of discharge was addressed by placing a whiteboard in the room that physicians would use to catalogue the benchmarks for discharge as well as an anticipated discharge date and time; delays in social work planning were tackled by a five-minute “lightning round” between the doctors and the social workers at 8 a.m. every morning; redundant paperwork required to discharge a patient was consolidated.

On and on it went, every additional step exorcising another discharge gremlin.

Then something interesting happened.

We realized the key to efficiency lie not in changing one or two giant unruly processes rather in effecting multiple very small changes.

No one individual or system was to blame for delayed discharges. Years of patches, work-arounds and waste had accumulated in our system like the layers of paint covering the grime on the walls of an old house. We would need to slowly—but surely—chip away at these layers if we were going to achieve our goals. None of us were convinced these immediate changes would solve our problem, but for the first time we felt empowered to make the kind of changes that would lead us to real systems improvement.

Then something interesting happened.

The second day ended. We’d made a ton of progress and I didn’t even need to invoke that fake emergency page. TH

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

How did I get myself into this and, more importantly, how could I get out of it?

I could act like I had inadvertently shown up at the wrong room, “so sorry to barge in, I’ll be on my way now.” Or, I could fake an important page that would require me to attend to an “emergency.” Or, I could just tell the group, “look, as much as I’d love to meet with you all for two straight days, I really have more important things to do with my time.”

Problem was I had been part of the decision to call this meeting in the first place. What was I thinking?

For years I’ve sat on a capacity management committee that met frequently and tackled various projects, such as reducing length of stay, discharging patients earlier in the day, and improving the discharge process—all of which fell under the rubric of efficiently moving patients through the system so we could create space for more patients. This not only makes good business, sense but also is good for our patients who benefit from getting out of the hospital earlier and back to the recuperative comfort of their homes.

The committee had met for hours on end, discussing new methods to tackle old problems. What if…we developed a follow-up clinic that could see patients back shortly after discharge, had a discharge nurse whose only responsibility was to discharge patients, had a lounge that could hold discharged patients waiting for a ride, and so on.

Hour after hour, meeting after meeting, we searched for the elusive Rosetta stone that would unlock the mystery of the timely discharge. We often implemented a large intervention, then met again only to find that our glorious idea came up short. We’d scratch our heads, find someone to pin the blame on for these shortcomings and move on to the next doomed project. Ideas were waning, patience was frayed and morale was at an all-time low.

At our wits end we decided to get thinner, reduce waste, make cars.

Ok, not literally make cars but to use the methodology of the Toyota Production System (TPS) to remove waste, to get lean. Sounded like a good idea until I settled into my hardback chair for the meeting that first morning. I quickly was filled with the ominous dread that only results from mixing consultants, a trough full of meeting-issue scrambled eggs congealing over a Sterno flame, and a roomful of sleepy-eyed participants. Sprinkle in a two-day agenda and we had all the ingredients for a scalding caldron of tedium, bubbling over with boredom.

Then something interesting happened.

I became interested.

Our consultants initiated our journey by discussing the basis of lean Toyota production—the theory of Kaizen, or “change (Kai) for the good (Zen).” The essence of the process included multi-day continuous sessions (yikes) utilizing a cross-functional team consisting of leadership and front-line staff from all hospital disciplines—from doctors to nurses to transport to janitorial staff. It also focused on fast, continuous, experimental change.

Then something interesting happened.

We left the room.

A meeting that didn’t meet? What was this strange Japanese system? Well it turns out that another key tenet of the TPS is “gemba,” meaning “shop floor.” The idea is to spend as much time as possible observing the actual processes, out on the shop floor, not in the board room. So, rather than wallowing away in a meeting discussing what we thought the problem was, we actually went to see what the problem was.

We split into teams and were instructed to observe various parts of the discharge process. Specifically, we were charged with differentiating between processes that add value—things people would pay for—and processes that did not add value—things people wouldn’t pay for.

It is estimated that up to 40% of a nurse’s day is spent “nursing” an inefficient system. Any hospitalist who has spent time holding on the phone, chasing down a CT scan report, or scouring the documentation vortex that mysteriously confiscate charts only to just as mysteriously cough them back up 20 minutes later, knows how much time is wasted in a typical day.

Then something interesting happened.

We realized broken systems, not people, were to blame for most of our problems.

After several hours of observation the teams reconvened and discussed their findings. We discovered that efficiently discharging patients earlier in the day could not be accomplished simply by imploring the physicians to write the orders earlier in the day, an intervention that had been continuously failing since I was an intern 12 years earlier.

In fact, the committee discovered there wasn’t a single unifying solution to this problem. Rather, hundreds of gremlins were dwelling within the recesses of our hospital, together gumming up the system. In just one day of observation, our teams identified 70 different contused processes causing our system to hemorrhage inefficiency.

Then something interesting happened.

It was time to go home; our first day was complete.

The second day of Kaizen centered on “tests of change” that could be implemented immediately and then studied for effect. Each group proffered ideas to solve identified problems and then began implementing these changes, taking time to alter the intervention whenever a better method was uncovered.

For example, an inability to timely locate wheelchairs was slowing the transport of discharged patients out of the hospital. This problem was resolved by designating two wheelchairs for this activity alone; a lack of communication with the patient, family and nursing about the timing of discharge was addressed by placing a whiteboard in the room that physicians would use to catalogue the benchmarks for discharge as well as an anticipated discharge date and time; delays in social work planning were tackled by a five-minute “lightning round” between the doctors and the social workers at 8 a.m. every morning; redundant paperwork required to discharge a patient was consolidated.

On and on it went, every additional step exorcising another discharge gremlin.

Then something interesting happened.

We realized the key to efficiency lie not in changing one or two giant unruly processes rather in effecting multiple very small changes.

No one individual or system was to blame for delayed discharges. Years of patches, work-arounds and waste had accumulated in our system like the layers of paint covering the grime on the walls of an old house. We would need to slowly—but surely—chip away at these layers if we were going to achieve our goals. None of us were convinced these immediate changes would solve our problem, but for the first time we felt empowered to make the kind of changes that would lead us to real systems improvement.

Then something interesting happened.

The second day ended. We’d made a ton of progress and I didn’t even need to invoke that fake emergency page. TH

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

Balance—that unrelenting chemistry project necessary to maintain our sanity. In its simplest form, balance means achieving harmony in work and life, job and home, career and family. However, as we move along the life continuum this straightforward linear equation can take on second, third, seemingly infinite dimensions.

Children need raising, marriages need cultivation, friendships need nurturing, lawns need mowing, books need reading, waistlines need shrinking, charities need volunteering, extended family need visiting, dogs need walking, minds need relaxing, beds need sleeping in, and so on and so forth.

Add to this concoction a full-time hospitalist job with its clinical demands, night shifts, long stretches of days, administrative or scholarly duties, and patients’ emotional needs and you have a volatile cauldron that’s nearly impossible to keep from boiling over.

Thus, the need to maintain perspective, keep even, and stay in balance. We all have our own means to maintain balance and methods to measure if we are in or out of it. For me, it all comes down to left turns.

I moved to Denver in the mid-’90s to do my residency in internal medicine. Prior to that, balance wasn’t something I thought much about. Certainly there were times when the work-life continuum strayed too far toward the former—especially during the doldrums of medical school. However, it wasn’t until residency that I began to feel the true equilibrium tug-of-war.

At the time, I wasn’t juggling nearly as many balls as I am now, but nonetheless it was easy to become discombobulated. With limitless work hours, every fourth night call with 36-plus-hour shifts, morning report preparations, and the occasional harrowing attending rounds, finding ways to let off steam became paramount. I had moved to Colorado partly to enjoy its natural bounty. With the foothills a mere 30 minutes away and the high country within an hour’s drive, I frequently recharged by heading west for a hike, snow shoe, or cross country ski. Driving north from my house in central Denver you quickly come to Interstate 70, which traverses the state of Colorado, east to west. For me, I-70 is more than just a means of transportation; it is the scale upon which I measure my life’s balance. A trip east takes me to the airport and the hospital at which I work. A trip west takes me to the mountains. Right turn = travel, work, stress. Left turn = recreation, exercise, relaxation. Reflecting on my ratio of right to left turns is a simple and sure means to gauge my level of balance.

Maintaining enough left turns is one of the key issues facing the field of hospital medicine. As a young, exciting, and rapidly growing field it’s easy to become overwhelmed in our jobs. For most of us, our first hospitalist jobs felt comfortable: basically residency with less hours and more pay. However, as it turns out, the hospitalist job’s similarity to residency is one of the biggest hurdles we face.

Studies of internal medicine residency programs have revealed that up to three-quarters of residents are burned out.1,2 This doesn’t bode well for a field that strongly recruits from this burned-out pool of applicants and shares many of the structural elements that make residents so prone to burn out. The common causes of burnout—extended workloads, limited autonomy and control over one’s work-life, ambiguous employer expectations, deficient support systems, lack of stability and predictability—are mainstays of many hospitalist systems.

The only study to systematically evaluate hospitalist burnout found 13% of hospitalists were burned out with an additional 25% at risk for burnout.3 While this is a noteworthy improvement over the residency rates, it is likely the rate has risen significantly since the study was completed in 1999. Even if it hasn’t, it’s concerning to build a hospitalist group (let alone an entire field) with about 40% of its base nearing or completely burned out. Burnout is associated with employee turnover, reduced individual and group morale, and—quite possibly—worse patient outcomes.

As such, it is incumbent upon hospitalists and hospitalist group leaders to promote healthy work environments. In most cases, this doesn’t mean making changes to reinvigorate a burned-out employee (although this may be necessary). Rather, it involves targeting the larger organizational structure to mitigate the factors that promote burnout in the first place.

A successful group must provide individuals control over its work environment to help offset the hefty demands the job levies on hospitalists. Individual hospitalists should have a voice in the group’s decision-making and scheduling process. This encourages ownership in the group’s future; ownership is inversely associated with burnout. Further, attempts should be made to reduce the unpredictability of the job as much as possible. This should include setting and maintaining clear expectations, having back-up systems to deal with unexpected spikes in volume or an ill colleague, and placing hard caps on the number of encounters per day. Finally, a group should strive to provide hospitalists with flexible scheduling so that, when necessary, they can care for a child or a sick relative, limit the number of consecutive shifts worked and ensure adequate time away from work.

Which brings us back to balance.

It ultimately falls to each of us to ensure that we remain on kilter. As the summer draws to a close, take a quick biopsy of your level of balance. If you’re a bit out of whack, make an effort to realign. Take some extra time with your kids, spend a night alone with your spouse, go to bed early and read by yourself. Take a left turn. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, 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. Gopal R, Glasheen JJ, Miyoshi T, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595-2600.
2. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Arch Intern Med. 2002;136(5):358-67
3. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91

Balance—that unrelenting chemistry project necessary to maintain our sanity. In its simplest form, balance means achieving harmony in work and life, job and home, career and family. However, as we move along the life continuum this straightforward linear equation can take on second, third, seemingly infinite dimensions.

Children need raising, marriages need cultivation, friendships need nurturing, lawns need mowing, books need reading, waistlines need shrinking, charities need volunteering, extended family need visiting, dogs need walking, minds need relaxing, beds need sleeping in, and so on and so forth.

Add to this concoction a full-time hospitalist job with its clinical demands, night shifts, long stretches of days, administrative or scholarly duties, and patients’ emotional needs and you have a volatile cauldron that’s nearly impossible to keep from boiling over.

Thus, the need to maintain perspective, keep even, and stay in balance. We all have our own means to maintain balance and methods to measure if we are in or out of it. For me, it all comes down to left turns.

I moved to Denver in the mid-’90s to do my residency in internal medicine. Prior to that, balance wasn’t something I thought much about. Certainly there were times when the work-life continuum strayed too far toward the former—especially during the doldrums of medical school. However, it wasn’t until residency that I began to feel the true equilibrium tug-of-war.

At the time, I wasn’t juggling nearly as many balls as I am now, but nonetheless it was easy to become discombobulated. With limitless work hours, every fourth night call with 36-plus-hour shifts, morning report preparations, and the occasional harrowing attending rounds, finding ways to let off steam became paramount. I had moved to Colorado partly to enjoy its natural bounty. With the foothills a mere 30 minutes away and the high country within an hour’s drive, I frequently recharged by heading west for a hike, snow shoe, or cross country ski. Driving north from my house in central Denver you quickly come to Interstate 70, which traverses the state of Colorado, east to west. For me, I-70 is more than just a means of transportation; it is the scale upon which I measure my life’s balance. A trip east takes me to the airport and the hospital at which I work. A trip west takes me to the mountains. Right turn = travel, work, stress. Left turn = recreation, exercise, relaxation. Reflecting on my ratio of right to left turns is a simple and sure means to gauge my level of balance.

Maintaining enough left turns is one of the key issues facing the field of hospital medicine. As a young, exciting, and rapidly growing field it’s easy to become overwhelmed in our jobs. For most of us, our first hospitalist jobs felt comfortable: basically residency with less hours and more pay. However, as it turns out, the hospitalist job’s similarity to residency is one of the biggest hurdles we face.

Studies of internal medicine residency programs have revealed that up to three-quarters of residents are burned out.1,2 This doesn’t bode well for a field that strongly recruits from this burned-out pool of applicants and shares many of the structural elements that make residents so prone to burn out. The common causes of burnout—extended workloads, limited autonomy and control over one’s work-life, ambiguous employer expectations, deficient support systems, lack of stability and predictability—are mainstays of many hospitalist systems.

The only study to systematically evaluate hospitalist burnout found 13% of hospitalists were burned out with an additional 25% at risk for burnout.3 While this is a noteworthy improvement over the residency rates, it is likely the rate has risen significantly since the study was completed in 1999. Even if it hasn’t, it’s concerning to build a hospitalist group (let alone an entire field) with about 40% of its base nearing or completely burned out. Burnout is associated with employee turnover, reduced individual and group morale, and—quite possibly—worse patient outcomes.

As such, it is incumbent upon hospitalists and hospitalist group leaders to promote healthy work environments. In most cases, this doesn’t mean making changes to reinvigorate a burned-out employee (although this may be necessary). Rather, it involves targeting the larger organizational structure to mitigate the factors that promote burnout in the first place.

A successful group must provide individuals control over its work environment to help offset the hefty demands the job levies on hospitalists. Individual hospitalists should have a voice in the group’s decision-making and scheduling process. This encourages ownership in the group’s future; ownership is inversely associated with burnout. Further, attempts should be made to reduce the unpredictability of the job as much as possible. This should include setting and maintaining clear expectations, having back-up systems to deal with unexpected spikes in volume or an ill colleague, and placing hard caps on the number of encounters per day. Finally, a group should strive to provide hospitalists with flexible scheduling so that, when necessary, they can care for a child or a sick relative, limit the number of consecutive shifts worked and ensure adequate time away from work.

Which brings us back to balance.

It ultimately falls to each of us to ensure that we remain on kilter. As the summer draws to a close, take a quick biopsy of your level of balance. If you’re a bit out of whack, make an effort to realign. Take some extra time with your kids, spend a night alone with your spouse, go to bed early and read by yourself. Take a left turn. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, 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. Gopal R, Glasheen JJ, Miyoshi T, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595-2600.
2. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Arch Intern Med. 2002;136(5):358-67
3. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91

Balance—that unrelenting chemistry project necessary to maintain our sanity. In its simplest form, balance means achieving harmony in work and life, job and home, career and family. However, as we move along the life continuum this straightforward linear equation can take on second, third, seemingly infinite dimensions.

Children need raising, marriages need cultivation, friendships need nurturing, lawns need mowing, books need reading, waistlines need shrinking, charities need volunteering, extended family need visiting, dogs need walking, minds need relaxing, beds need sleeping in, and so on and so forth.

Add to this concoction a full-time hospitalist job with its clinical demands, night shifts, long stretches of days, administrative or scholarly duties, and patients’ emotional needs and you have a volatile cauldron that’s nearly impossible to keep from boiling over.

Thus, the need to maintain perspective, keep even, and stay in balance. We all have our own means to maintain balance and methods to measure if we are in or out of it. For me, it all comes down to left turns.

I moved to Denver in the mid-’90s to do my residency in internal medicine. Prior to that, balance wasn’t something I thought much about. Certainly there were times when the work-life continuum strayed too far toward the former—especially during the doldrums of medical school. However, it wasn’t until residency that I began to feel the true equilibrium tug-of-war.

At the time, I wasn’t juggling nearly as many balls as I am now, but nonetheless it was easy to become discombobulated. With limitless work hours, every fourth night call with 36-plus-hour shifts, morning report preparations, and the occasional harrowing attending rounds, finding ways to let off steam became paramount. I had moved to Colorado partly to enjoy its natural bounty. With the foothills a mere 30 minutes away and the high country within an hour’s drive, I frequently recharged by heading west for a hike, snow shoe, or cross country ski. Driving north from my house in central Denver you quickly come to Interstate 70, which traverses the state of Colorado, east to west. For me, I-70 is more than just a means of transportation; it is the scale upon which I measure my life’s balance. A trip east takes me to the airport and the hospital at which I work. A trip west takes me to the mountains. Right turn = travel, work, stress. Left turn = recreation, exercise, relaxation. Reflecting on my ratio of right to left turns is a simple and sure means to gauge my level of balance.

Maintaining enough left turns is one of the key issues facing the field of hospital medicine. As a young, exciting, and rapidly growing field it’s easy to become overwhelmed in our jobs. For most of us, our first hospitalist jobs felt comfortable: basically residency with less hours and more pay. However, as it turns out, the hospitalist job’s similarity to residency is one of the biggest hurdles we face.

Studies of internal medicine residency programs have revealed that up to three-quarters of residents are burned out.1,2 This doesn’t bode well for a field that strongly recruits from this burned-out pool of applicants and shares many of the structural elements that make residents so prone to burn out. The common causes of burnout—extended workloads, limited autonomy and control over one’s work-life, ambiguous employer expectations, deficient support systems, lack of stability and predictability—are mainstays of many hospitalist systems.

The only study to systematically evaluate hospitalist burnout found 13% of hospitalists were burned out with an additional 25% at risk for burnout.3 While this is a noteworthy improvement over the residency rates, it is likely the rate has risen significantly since the study was completed in 1999. Even if it hasn’t, it’s concerning to build a hospitalist group (let alone an entire field) with about 40% of its base nearing or completely burned out. Burnout is associated with employee turnover, reduced individual and group morale, and—quite possibly—worse patient outcomes.

As such, it is incumbent upon hospitalists and hospitalist group leaders to promote healthy work environments. In most cases, this doesn’t mean making changes to reinvigorate a burned-out employee (although this may be necessary). Rather, it involves targeting the larger organizational structure to mitigate the factors that promote burnout in the first place.

A successful group must provide individuals control over its work environment to help offset the hefty demands the job levies on hospitalists. Individual hospitalists should have a voice in the group’s decision-making and scheduling process. This encourages ownership in the group’s future; ownership is inversely associated with burnout. Further, attempts should be made to reduce the unpredictability of the job as much as possible. This should include setting and maintaining clear expectations, having back-up systems to deal with unexpected spikes in volume or an ill colleague, and placing hard caps on the number of encounters per day. Finally, a group should strive to provide hospitalists with flexible scheduling so that, when necessary, they can care for a child or a sick relative, limit the number of consecutive shifts worked and ensure adequate time away from work.

Which brings us back to balance.

It ultimately falls to each of us to ensure that we remain on kilter. As the summer draws to a close, take a quick biopsy of your level of balance. If you’re a bit out of whack, make an effort to realign. Take some extra time with your kids, spend a night alone with your spouse, go to bed early and read by yourself. Take a left turn. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, 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. Gopal R, Glasheen JJ, Miyoshi T, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595-2600.
2. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Arch Intern Med. 2002;136(5):358-67
3. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91

A sea of pimples and drooling yawns. That’s what was staring, glassy-eyed back at me.

More realistically they were staring through me—through space, actually—to 50 minutes into the future. The look inhabited the hinterlands between boredom and loathing. A less-trained eye would mistake their tranquil countenances as anticipatory rapture. However, years of educating medical students and residents taught me that this was the look of those residing serenely in their own world, eons away from the classroom.

Then the ring of the first-period bell jolted me from my thoughts.

It was 7:45 a.m., and I found myself back at my hometown high school—jettisoned 20 years back in time. Months earlier I had agreed to teach a health and biology class as a visiting teacher as part of a career-planning program. I was instructed to teach them about what I do in my professional life. At the time I foolishly imagined a cohort of eagerly engrossed students hanging on my every word. What I found was more in line with a pack of sedated sloths sleepily hanging from the tedium tree.

My folly became even more obvious when I introduced my title slide: “The Epidemic of Medical Error.”

What was I thinking trying to teach 14-year-old kids about patient safety and medical error? Months before the talk I had agreed to this topic only after the principal assured me this would be of great interest to high school freshman and sophomores. It wasn’t until the week before the talk that the unease set in.

Could I really interest hormone-raged pubescent teenagers in the intricacies of hospital patient safety? My wife, ever helpful, was instrumental in triggering this epiphany. She noted that 14-year-olds are really only interested in … well, nothing. The prospect of engaging them in the complexities of hospital healthcare seemed about as likely as getting a trout excited over a fish fry.

Engaged they were not; in fact, some narcoleptic kid in the back had already engaged REM sleep. I was only four minutes into this and I was already foundering miserably. I had become that teacher. You know the one. He is so exceptionally mind-numbing that you wonder if he was brought in as some sort of social experiment testing the currently known limits of boredom.

Then someone had an, er, gastric accident.

The ensuing hilarity made it difficult to pinpoint the exact source or even if this was a true gastroenterological event or its ever-comical cousin, the armpit version. Now, I’m young enough to remember the comic genius of well-timed and executed classroom flatus. As such I understood that this was clearly intended as a territorial marking. The natives had spoken; there was an enemy among them.

As the clock metamorphosed into one of those melting Dali timepieces, we commenced discussion of three cases. The first involved a man who had the wrong leg amputated. The second reviewed the case of young women who suffered devastating consequences after an ICU medication was dropped off her medication list upon transfer to a medical ward team. The final case involved a patient with a myocardial infarction who did not receive aspirin upon admission to the hospital.

An interesting thing happened after I presented the first case. They were interested. It seems cutting off the wrong leg resonates with high school students. Moreover they were aghast that these types of medical errors were occurring. They were shocked that such smart people could make such dumb mistakes. Mr. Narcolepsy slid out of stage 1 sleep long enough to sarcastically note that even he knew that heart attack patients should get aspirin.

I asked them how they thought we could avoid these mistakes. A girl in the front wondered if we couldn’t just ask the patient which leg they wanted cut off. I noted that patients are anesthetized when we meet them for the surgery. She then proffered that perhaps we could ask them while they were awake and then mark the correct leg with a marker prior to going into the operating room.

Regarding the ICU transfer patient who had a medication drop off her med list, a quiet kid in the front asked, “Why don’t you just compare the list of medications used in the ICU to those outside of the ICU?” Another suggested that the two different teams of doctors could sit down and discuss the patient’s medications to be sure nothing was left off.

They wondered if we could avoid forgetting important medications—such as was done with the aspirin for the MI patient—by making a list of the things every patient with a heart attack would need. For example, didn’t they need an EKG, some lab tests, and some medications? Wouldn’t it be best to just have this list so that we didn’t have to remember all these things?

Unwittingly, these teen-agers—none old enough to shave—had just in their own words recited some of the key tenets of the patient safety movement:

• Active communication with the patient prior to surgery;
• Time out prior to surgery to ensure correct patient and surgery;
• Marking the site of surgery;
• Improved communication around patient handoffs;
• Medication reconciliation at every transfer of care; and
• Use of protocols to ensure best practices.

I was floored. In 30 minutes, a group of teenagers had developed a list of hospital safety measures that it has taken modern medicine generations to grasp.

The amount of medical errors has risen in step with the complexity of the medical care we provide. However, this does not mean that the causes of these medical errors are complex. Rather, most errors result from simple mistakes and systems issues. In fact, as I was taught on that fateful spring morning, I learned everything I need to know about patient safety in high school. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, 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.

A sea of pimples and drooling yawns. That’s what was staring, glassy-eyed back at me.

More realistically they were staring through me—through space, actually—to 50 minutes into the future. The look inhabited the hinterlands between boredom and loathing. A less-trained eye would mistake their tranquil countenances as anticipatory rapture. However, years of educating medical students and residents taught me that this was the look of those residing serenely in their own world, eons away from the classroom.

Then the ring of the first-period bell jolted me from my thoughts.

It was 7:45 a.m., and I found myself back at my hometown high school—jettisoned 20 years back in time. Months earlier I had agreed to teach a health and biology class as a visiting teacher as part of a career-planning program. I was instructed to teach them about what I do in my professional life. At the time I foolishly imagined a cohort of eagerly engrossed students hanging on my every word. What I found was more in line with a pack of sedated sloths sleepily hanging from the tedium tree.

My folly became even more obvious when I introduced my title slide: “The Epidemic of Medical Error.”

What was I thinking trying to teach 14-year-old kids about patient safety and medical error? Months before the talk I had agreed to this topic only after the principal assured me this would be of great interest to high school freshman and sophomores. It wasn’t until the week before the talk that the unease set in.

Could I really interest hormone-raged pubescent teenagers in the intricacies of hospital patient safety? My wife, ever helpful, was instrumental in triggering this epiphany. She noted that 14-year-olds are really only interested in … well, nothing. The prospect of engaging them in the complexities of hospital healthcare seemed about as likely as getting a trout excited over a fish fry.

Engaged they were not; in fact, some narcoleptic kid in the back had already engaged REM sleep. I was only four minutes into this and I was already foundering miserably. I had become that teacher. You know the one. He is so exceptionally mind-numbing that you wonder if he was brought in as some sort of social experiment testing the currently known limits of boredom.

Then someone had an, er, gastric accident.

The ensuing hilarity made it difficult to pinpoint the exact source or even if this was a true gastroenterological event or its ever-comical cousin, the armpit version. Now, I’m young enough to remember the comic genius of well-timed and executed classroom flatus. As such I understood that this was clearly intended as a territorial marking. The natives had spoken; there was an enemy among them.

As the clock metamorphosed into one of those melting Dali timepieces, we commenced discussion of three cases. The first involved a man who had the wrong leg amputated. The second reviewed the case of young women who suffered devastating consequences after an ICU medication was dropped off her medication list upon transfer to a medical ward team. The final case involved a patient with a myocardial infarction who did not receive aspirin upon admission to the hospital.

An interesting thing happened after I presented the first case. They were interested. It seems cutting off the wrong leg resonates with high school students. Moreover they were aghast that these types of medical errors were occurring. They were shocked that such smart people could make such dumb mistakes. Mr. Narcolepsy slid out of stage 1 sleep long enough to sarcastically note that even he knew that heart attack patients should get aspirin.

I asked them how they thought we could avoid these mistakes. A girl in the front wondered if we couldn’t just ask the patient which leg they wanted cut off. I noted that patients are anesthetized when we meet them for the surgery. She then proffered that perhaps we could ask them while they were awake and then mark the correct leg with a marker prior to going into the operating room.

Regarding the ICU transfer patient who had a medication drop off her med list, a quiet kid in the front asked, “Why don’t you just compare the list of medications used in the ICU to those outside of the ICU?” Another suggested that the two different teams of doctors could sit down and discuss the patient’s medications to be sure nothing was left off.

They wondered if we could avoid forgetting important medications—such as was done with the aspirin for the MI patient—by making a list of the things every patient with a heart attack would need. For example, didn’t they need an EKG, some lab tests, and some medications? Wouldn’t it be best to just have this list so that we didn’t have to remember all these things?

Unwittingly, these teen-agers—none old enough to shave—had just in their own words recited some of the key tenets of the patient safety movement:

• Active communication with the patient prior to surgery;
• Time out prior to surgery to ensure correct patient and surgery;
• Marking the site of surgery;
• Improved communication around patient handoffs;
• Medication reconciliation at every transfer of care; and
• Use of protocols to ensure best practices.

I was floored. In 30 minutes, a group of teenagers had developed a list of hospital safety measures that it has taken modern medicine generations to grasp.

The amount of medical errors has risen in step with the complexity of the medical care we provide. However, this does not mean that the causes of these medical errors are complex. Rather, most errors result from simple mistakes and systems issues. In fact, as I was taught on that fateful spring morning, I learned everything I need to know about patient safety in high school. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, 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.

A sea of pimples and drooling yawns. That’s what was staring, glassy-eyed back at me.

More realistically they were staring through me—through space, actually—to 50 minutes into the future. The look inhabited the hinterlands between boredom and loathing. A less-trained eye would mistake their tranquil countenances as anticipatory rapture. However, years of educating medical students and residents taught me that this was the look of those residing serenely in their own world, eons away from the classroom.

Then the ring of the first-period bell jolted me from my thoughts.

It was 7:45 a.m., and I found myself back at my hometown high school—jettisoned 20 years back in time. Months earlier I had agreed to teach a health and biology class as a visiting teacher as part of a career-planning program. I was instructed to teach them about what I do in my professional life. At the time I foolishly imagined a cohort of eagerly engrossed students hanging on my every word. What I found was more in line with a pack of sedated sloths sleepily hanging from the tedium tree.

My folly became even more obvious when I introduced my title slide: “The Epidemic of Medical Error.”

What was I thinking trying to teach 14-year-old kids about patient safety and medical error? Months before the talk I had agreed to this topic only after the principal assured me this would be of great interest to high school freshman and sophomores. It wasn’t until the week before the talk that the unease set in.

Could I really interest hormone-raged pubescent teenagers in the intricacies of hospital patient safety? My wife, ever helpful, was instrumental in triggering this epiphany. She noted that 14-year-olds are really only interested in … well, nothing. The prospect of engaging them in the complexities of hospital healthcare seemed about as likely as getting a trout excited over a fish fry.

Engaged they were not; in fact, some narcoleptic kid in the back had already engaged REM sleep. I was only four minutes into this and I was already foundering miserably. I had become that teacher. You know the one. He is so exceptionally mind-numbing that you wonder if he was brought in as some sort of social experiment testing the currently known limits of boredom.

Then someone had an, er, gastric accident.

The ensuing hilarity made it difficult to pinpoint the exact source or even if this was a true gastroenterological event or its ever-comical cousin, the armpit version. Now, I’m young enough to remember the comic genius of well-timed and executed classroom flatus. As such I understood that this was clearly intended as a territorial marking. The natives had spoken; there was an enemy among them.

As the clock metamorphosed into one of those melting Dali timepieces, we commenced discussion of three cases. The first involved a man who had the wrong leg amputated. The second reviewed the case of young women who suffered devastating consequences after an ICU medication was dropped off her medication list upon transfer to a medical ward team. The final case involved a patient with a myocardial infarction who did not receive aspirin upon admission to the hospital.

An interesting thing happened after I presented the first case. They were interested. It seems cutting off the wrong leg resonates with high school students. Moreover they were aghast that these types of medical errors were occurring. They were shocked that such smart people could make such dumb mistakes. Mr. Narcolepsy slid out of stage 1 sleep long enough to sarcastically note that even he knew that heart attack patients should get aspirin.

I asked them how they thought we could avoid these mistakes. A girl in the front wondered if we couldn’t just ask the patient which leg they wanted cut off. I noted that patients are anesthetized when we meet them for the surgery. She then proffered that perhaps we could ask them while they were awake and then mark the correct leg with a marker prior to going into the operating room.

Regarding the ICU transfer patient who had a medication drop off her med list, a quiet kid in the front asked, “Why don’t you just compare the list of medications used in the ICU to those outside of the ICU?” Another suggested that the two different teams of doctors could sit down and discuss the patient’s medications to be sure nothing was left off.

They wondered if we could avoid forgetting important medications—such as was done with the aspirin for the MI patient—by making a list of the things every patient with a heart attack would need. For example, didn’t they need an EKG, some lab tests, and some medications? Wouldn’t it be best to just have this list so that we didn’t have to remember all these things?

Unwittingly, these teen-agers—none old enough to shave—had just in their own words recited some of the key tenets of the patient safety movement:

• Active communication with the patient prior to surgery;
• Time out prior to surgery to ensure correct patient and surgery;
• Marking the site of surgery;
• Improved communication around patient handoffs;
• Medication reconciliation at every transfer of care; and
• Use of protocols to ensure best practices.

I was floored. In 30 minutes, a group of teenagers had developed a list of hospital safety measures that it has taken modern medicine generations to grasp.

The amount of medical errors has risen in step with the complexity of the medical care we provide. However, this does not mean that the causes of these medical errors are complex. Rather, most errors result from simple mistakes and systems issues. In fact, as I was taught on that fateful spring morning, I learned everything I need to know about patient safety in high school. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, 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.