Jeff Glasheen, MD, SFHM

By now you are no doubt aware that the world will soon end. And by soon, I don’t mean Dec. 21, 2012, as predicted by the Mayans—rather, July 21, the date the Weekly World News recently reported that the Earth will hurdle into the planet Nibiru, no doubt inconveniencing my son’s tee-ball game and upending my father’s 72nd annual failed attempt at pulling off the white T, black socks, and sandals look at the beach.

The tabloid also reports that Elvis was spotted pilfering a Vegas buffet (photos of inexplicably barren shrimp cocktail containers support their case), a manigator is loose in Alabama (heads up if you’re reading this in Mobile!), and that duck hunters mistakenly shot an angel (bad move angering the angels right before Doomsday).

OK, maybe you don’t believe that the world will end in 2012. But one thing that will end is my tenure as physician editor of The Hospitalist. The date: March 31, 2012. Yes, after nearly five years, I’m passing the baton and moving on before my editing career takes on an overweight, beefy side-burned, flowing-jumpsuit-in-Vegas course of its own.

And after editing and writing columns for 55 issues of the definitive publication in hospital medicine, what question do I get the most?

How’s Hogan?

History Through Headlines

Looking back at my columns, I now see that some themes developed. I touched on disease states (Spanish Flu Redux?), obesity (Fight the Losing Battle), electronic health records (Only Fools Rush In), patient satisfaction (Doctor Remodel), physician burnout (Left Turns), and healthcare reform (Get Well Now). I wrote about the births of my children, Greyson (Lesson of the Titanic) and Kaiya (Undercover, MD), Grey’s trip to the ED (Mind Games & Silence), and the myriad ways my father can irritate from the backseat of a car (Minivan, Major Lesson).

But over the years, I also increasingly wrote about patient safety (Bueller … Bueller?; Handless Employees; Designed to Harm; A Run For Safety), quality improvement (Something Interesting Happened; Quality Defined) and the need for hospitalists to lead these imperatives (Exceed Acceptable; Promise or Insanity?; Subsidy or Payment?; Fiddling As HM Burns).

And along the way, my monologue turned into a dialogue. I remember the first email that proved someone other than my coerced wife read my column. Then again, I shouldn’t have been surprised that my dad emailed to tell me to stop writing about him.

But then it happened again. And again. And again.

I was surprised to hear from so many readers. People wrote that they, too, had embarrassingly misdiagnosed their child’s croup as a life-threatening disorder, were struggling with burnout and balance, didn’t like the new ABIM recognition of focused practice in hospital medicine (Urban Legends; Certified Special), and, in the case of my chair of medicine, that they could not achieve my challenge (Transitions Telethon) to call every PCP on discharge for one week.

Readers wrote that I made them laugh, that a story touched them, or that they were angry. One was upset that I called childbirth a “miracle,” another that I was too forgiving about the new duty hours (Rise of the Napturnist), and my father that I still hadn’t stopped writing about him.

But none of this generated the interest that Hogan did.

What Would Hogan Want?

In August 2009, I wrote The Anvil of Indecision column about my dog, Hogan, and our experience with his incidentally discovered 5-cm lung mass. It was my first personal foray into end-of-life decision-making, and it came in the form of a 10-year-old Weimaraner. Hogan was present for many of the most important strata of my life—his rings counting my single-guy resident days, early hospitalist career, marriage, a few relocations, and the births of my kids. And along the way, he was the one constant, the glue that kept my life together.

Best friends are like that.

As I noted in that column, my wife and I struggled with “how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.” Not knowing if the mass was benign or malignant, should we work it up or just let nature sort it out? If we treated, should we diagnose and stage the tumor, blindly surgically remove it, or just give palliative chemotherapy? What if it was isolated and surgery would be curative? What if it was metastatic and surgery just added morbidity? What if this was benign and Hogan died in the operating room? What would Hogan want? Hogan trusted me to make the right decision.

Best friends are like that.

This was the easiest column I’d ever typed but the hardest I’d ever written. I wrote it in about an hour and then cried about it for two days. I was distraught, miserable, and unmoored in the way that only pet-lovers who have faced the demise of a loved one can understand.

I was truly confounded, and the act of writing was cathartic. It was my first venture beyond standard professional content. I spent two weeks deciding if I could really publish it. It was difficult, I found, to expose myself—to be vulnerable in this manner.

No one can beat you up for saying we should care about patient safety and improve quality. Dedicating an entire column to a dog? What if my peers, the society, my bosses found it immature or self-pitying? What if they didn’t get it?

Within days of publishing the column about Hogan, I’d received hundreds of comments from readers, most relating their similar experiences, all expressing support—by far more interest than I got about anything else I’d written.

Turns out, you got it.

What’s Next?

I wonder what my next 55 columns would have looked like. I surely would continue to discuss HM’s struggles to operationalize the quality and safety promise we hold. This should continue to be our singular goal.

I’d likely write about bundled payments and ACOs. I believe these are potential game-changers in much the same way the prospective payment system was in the 1980s. The latter laid the groundwork for hospitalists. Will new payment models prove a boon or a death knell?

I’d spill ink, no doubt, about the financing of HM groups. As hospital reimbursement fades, can hospitalist salaries be far behind? Will this push us toward more encounters and more shifts, leaving less time for meaningful process improvement work, less time for personal and professional balance, less satisfaction in our careers?

I would wrestle with how we can attract the best and brightest to our field. Who will fill the next 20,000 hospitalist positions?

I would, no doubt, chronicle the tribulations of my kids (a record to be leveraged when I look to move in with them in 2040), send a few more barbs my father’s way (payback for the 1980s, Dad!), and deprecate a few of my future dimwitted moves.

And I might even devote a few more inches of column to Hogan.

Because, you see, Hogan is doing well. He’s cancer-free nearly three years after surgery and chemotherapy for metastatic pulmonary adenocarcinoma. I’ll skip the details and just say “thanks.”

Thanks for asking. Thanks for reading.

Dr. Glasheen is physician editor of The Hospitalist.

By now you are no doubt aware that the world will soon end. And by soon, I don’t mean Dec. 21, 2012, as predicted by the Mayans—rather, July 21, the date the Weekly World News recently reported that the Earth will hurdle into the planet Nibiru, no doubt inconveniencing my son’s tee-ball game and upending my father’s 72nd annual failed attempt at pulling off the white T, black socks, and sandals look at the beach.

The tabloid also reports that Elvis was spotted pilfering a Vegas buffet (photos of inexplicably barren shrimp cocktail containers support their case), a manigator is loose in Alabama (heads up if you’re reading this in Mobile!), and that duck hunters mistakenly shot an angel (bad move angering the angels right before Doomsday).

OK, maybe you don’t believe that the world will end in 2012. But one thing that will end is my tenure as physician editor of The Hospitalist. The date: March 31, 2012. Yes, after nearly five years, I’m passing the baton and moving on before my editing career takes on an overweight, beefy side-burned, flowing-jumpsuit-in-Vegas course of its own.

And after editing and writing columns for 55 issues of the definitive publication in hospital medicine, what question do I get the most?

How’s Hogan?

History Through Headlines

Looking back at my columns, I now see that some themes developed. I touched on disease states (Spanish Flu Redux?), obesity (Fight the Losing Battle), electronic health records (Only Fools Rush In), patient satisfaction (Doctor Remodel), physician burnout (Left Turns), and healthcare reform (Get Well Now). I wrote about the births of my children, Greyson (Lesson of the Titanic) and Kaiya (Undercover, MD), Grey’s trip to the ED (Mind Games & Silence), and the myriad ways my father can irritate from the backseat of a car (Minivan, Major Lesson).

But over the years, I also increasingly wrote about patient safety (Bueller … Bueller?; Handless Employees; Designed to Harm; A Run For Safety), quality improvement (Something Interesting Happened; Quality Defined) and the need for hospitalists to lead these imperatives (Exceed Acceptable; Promise or Insanity?; Subsidy or Payment?; Fiddling As HM Burns).

And along the way, my monologue turned into a dialogue. I remember the first email that proved someone other than my coerced wife read my column. Then again, I shouldn’t have been surprised that my dad emailed to tell me to stop writing about him.

But then it happened again. And again. And again.

I was surprised to hear from so many readers. People wrote that they, too, had embarrassingly misdiagnosed their child’s croup as a life-threatening disorder, were struggling with burnout and balance, didn’t like the new ABIM recognition of focused practice in hospital medicine (Urban Legends; Certified Special), and, in the case of my chair of medicine, that they could not achieve my challenge (Transitions Telethon) to call every PCP on discharge for one week.

Readers wrote that I made them laugh, that a story touched them, or that they were angry. One was upset that I called childbirth a “miracle,” another that I was too forgiving about the new duty hours (Rise of the Napturnist), and my father that I still hadn’t stopped writing about him.

But none of this generated the interest that Hogan did.

What Would Hogan Want?

In August 2009, I wrote The Anvil of Indecision column about my dog, Hogan, and our experience with his incidentally discovered 5-cm lung mass. It was my first personal foray into end-of-life decision-making, and it came in the form of a 10-year-old Weimaraner. Hogan was present for many of the most important strata of my life—his rings counting my single-guy resident days, early hospitalist career, marriage, a few relocations, and the births of my kids. And along the way, he was the one constant, the glue that kept my life together.

Best friends are like that.

As I noted in that column, my wife and I struggled with “how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.” Not knowing if the mass was benign or malignant, should we work it up or just let nature sort it out? If we treated, should we diagnose and stage the tumor, blindly surgically remove it, or just give palliative chemotherapy? What if it was isolated and surgery would be curative? What if it was metastatic and surgery just added morbidity? What if this was benign and Hogan died in the operating room? What would Hogan want? Hogan trusted me to make the right decision.

Best friends are like that.

This was the easiest column I’d ever typed but the hardest I’d ever written. I wrote it in about an hour and then cried about it for two days. I was distraught, miserable, and unmoored in the way that only pet-lovers who have faced the demise of a loved one can understand.

I was truly confounded, and the act of writing was cathartic. It was my first venture beyond standard professional content. I spent two weeks deciding if I could really publish it. It was difficult, I found, to expose myself—to be vulnerable in this manner.

No one can beat you up for saying we should care about patient safety and improve quality. Dedicating an entire column to a dog? What if my peers, the society, my bosses found it immature or self-pitying? What if they didn’t get it?

Within days of publishing the column about Hogan, I’d received hundreds of comments from readers, most relating their similar experiences, all expressing support—by far more interest than I got about anything else I’d written.

Turns out, you got it.

What’s Next?

I wonder what my next 55 columns would have looked like. I surely would continue to discuss HM’s struggles to operationalize the quality and safety promise we hold. This should continue to be our singular goal.

I’d likely write about bundled payments and ACOs. I believe these are potential game-changers in much the same way the prospective payment system was in the 1980s. The latter laid the groundwork for hospitalists. Will new payment models prove a boon or a death knell?

I’d spill ink, no doubt, about the financing of HM groups. As hospital reimbursement fades, can hospitalist salaries be far behind? Will this push us toward more encounters and more shifts, leaving less time for meaningful process improvement work, less time for personal and professional balance, less satisfaction in our careers?

I would wrestle with how we can attract the best and brightest to our field. Who will fill the next 20,000 hospitalist positions?

I would, no doubt, chronicle the tribulations of my kids (a record to be leveraged when I look to move in with them in 2040), send a few more barbs my father’s way (payback for the 1980s, Dad!), and deprecate a few of my future dimwitted moves.

And I might even devote a few more inches of column to Hogan.

Because, you see, Hogan is doing well. He’s cancer-free nearly three years after surgery and chemotherapy for metastatic pulmonary adenocarcinoma. I’ll skip the details and just say “thanks.”

Thanks for asking. Thanks for reading.

Dr. Glasheen is physician editor of The Hospitalist.

By now you are no doubt aware that the world will soon end. And by soon, I don’t mean Dec. 21, 2012, as predicted by the Mayans—rather, July 21, the date the Weekly World News recently reported that the Earth will hurdle into the planet Nibiru, no doubt inconveniencing my son’s tee-ball game and upending my father’s 72nd annual failed attempt at pulling off the white T, black socks, and sandals look at the beach.

The tabloid also reports that Elvis was spotted pilfering a Vegas buffet (photos of inexplicably barren shrimp cocktail containers support their case), a manigator is loose in Alabama (heads up if you’re reading this in Mobile!), and that duck hunters mistakenly shot an angel (bad move angering the angels right before Doomsday).

OK, maybe you don’t believe that the world will end in 2012. But one thing that will end is my tenure as physician editor of The Hospitalist. The date: March 31, 2012. Yes, after nearly five years, I’m passing the baton and moving on before my editing career takes on an overweight, beefy side-burned, flowing-jumpsuit-in-Vegas course of its own.

And after editing and writing columns for 55 issues of the definitive publication in hospital medicine, what question do I get the most?

How’s Hogan?

History Through Headlines

Looking back at my columns, I now see that some themes developed. I touched on disease states (Spanish Flu Redux?), obesity (Fight the Losing Battle), electronic health records (Only Fools Rush In), patient satisfaction (Doctor Remodel), physician burnout (Left Turns), and healthcare reform (Get Well Now). I wrote about the births of my children, Greyson (Lesson of the Titanic) and Kaiya (Undercover, MD), Grey’s trip to the ED (Mind Games & Silence), and the myriad ways my father can irritate from the backseat of a car (Minivan, Major Lesson).

But over the years, I also increasingly wrote about patient safety (Bueller … Bueller?; Handless Employees; Designed to Harm; A Run For Safety), quality improvement (Something Interesting Happened; Quality Defined) and the need for hospitalists to lead these imperatives (Exceed Acceptable; Promise or Insanity?; Subsidy or Payment?; Fiddling As HM Burns).

And along the way, my monologue turned into a dialogue. I remember the first email that proved someone other than my coerced wife read my column. Then again, I shouldn’t have been surprised that my dad emailed to tell me to stop writing about him.

But then it happened again. And again. And again.

I was surprised to hear from so many readers. People wrote that they, too, had embarrassingly misdiagnosed their child’s croup as a life-threatening disorder, were struggling with burnout and balance, didn’t like the new ABIM recognition of focused practice in hospital medicine (Urban Legends; Certified Special), and, in the case of my chair of medicine, that they could not achieve my challenge (Transitions Telethon) to call every PCP on discharge for one week.

Readers wrote that I made them laugh, that a story touched them, or that they were angry. One was upset that I called childbirth a “miracle,” another that I was too forgiving about the new duty hours (Rise of the Napturnist), and my father that I still hadn’t stopped writing about him.

But none of this generated the interest that Hogan did.

What Would Hogan Want?

In August 2009, I wrote The Anvil of Indecision column about my dog, Hogan, and our experience with his incidentally discovered 5-cm lung mass. It was my first personal foray into end-of-life decision-making, and it came in the form of a 10-year-old Weimaraner. Hogan was present for many of the most important strata of my life—his rings counting my single-guy resident days, early hospitalist career, marriage, a few relocations, and the births of my kids. And along the way, he was the one constant, the glue that kept my life together.

Best friends are like that.

As I noted in that column, my wife and I struggled with “how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.” Not knowing if the mass was benign or malignant, should we work it up or just let nature sort it out? If we treated, should we diagnose and stage the tumor, blindly surgically remove it, or just give palliative chemotherapy? What if it was isolated and surgery would be curative? What if it was metastatic and surgery just added morbidity? What if this was benign and Hogan died in the operating room? What would Hogan want? Hogan trusted me to make the right decision.

Best friends are like that.

This was the easiest column I’d ever typed but the hardest I’d ever written. I wrote it in about an hour and then cried about it for two days. I was distraught, miserable, and unmoored in the way that only pet-lovers who have faced the demise of a loved one can understand.

I was truly confounded, and the act of writing was cathartic. It was my first venture beyond standard professional content. I spent two weeks deciding if I could really publish it. It was difficult, I found, to expose myself—to be vulnerable in this manner.

No one can beat you up for saying we should care about patient safety and improve quality. Dedicating an entire column to a dog? What if my peers, the society, my bosses found it immature or self-pitying? What if they didn’t get it?

Within days of publishing the column about Hogan, I’d received hundreds of comments from readers, most relating their similar experiences, all expressing support—by far more interest than I got about anything else I’d written.

Turns out, you got it.

What’s Next?

I wonder what my next 55 columns would have looked like. I surely would continue to discuss HM’s struggles to operationalize the quality and safety promise we hold. This should continue to be our singular goal.

I’d likely write about bundled payments and ACOs. I believe these are potential game-changers in much the same way the prospective payment system was in the 1980s. The latter laid the groundwork for hospitalists. Will new payment models prove a boon or a death knell?

I’d spill ink, no doubt, about the financing of HM groups. As hospital reimbursement fades, can hospitalist salaries be far behind? Will this push us toward more encounters and more shifts, leaving less time for meaningful process improvement work, less time for personal and professional balance, less satisfaction in our careers?

I would wrestle with how we can attract the best and brightest to our field. Who will fill the next 20,000 hospitalist positions?

I would, no doubt, chronicle the tribulations of my kids (a record to be leveraged when I look to move in with them in 2040), send a few more barbs my father’s way (payback for the 1980s, Dad!), and deprecate a few of my future dimwitted moves.

And I might even devote a few more inches of column to Hogan.

Because, you see, Hogan is doing well. He’s cancer-free nearly three years after surgery and chemotherapy for metastatic pulmonary adenocarcinoma. I’ll skip the details and just say “thanks.”

Thanks for asking. Thanks for reading.

Dr. Glasheen is physician editor of The Hospitalist.

I have a problem. OK, many problems. Marital discord, balky kids, bloated mortgage? No, fortunately, not those kinds of domestic problems—although I do struggle with reliably differentiating whites from darks. My biggest problem is work-related. And this isn’t new. Turns out, I have different problems at work every year. “Time to find a new job,” you say. Tell the boss to shove it? Produce an epic, Jerry Maguire-esque manifesto and ride off into the sunset with my goldfish and Renee Zellweger? Hmmm, Renee Zellweger…

No, no, that’s not it. Much more mundane, yet crucial, problems.

Problems like trying to sort out the implications of the impending value-based purchasing program—what does it mean for my group? How do I keep my hospitalist partners engaged, satisfied, and not burned out? How do I produce a schedule that emphasizes high-quality patient care, efficiency, and physician work-life balance? How can I reduce readmissions so my hospital administrator can go back to “administrating” someone other than me all day? What do I do with the perioperative beta blockade now that some of the original data have been called into question due to academic dishonesty? What does the Affordable Care Act really say, is it going stand up, and what does it mean for me, my patients, my salary, and my career?

These are all questions I am grappling with currently. They also are all questions that will be addressed at HM12, April 1-4 in San Diego. As such, I view the annual meeting as a kind of toolkit: Have a problem, reach into the HM12 toolkit, and pull out your solution. The beauty is its breadth. You might not care one iota about healthcare reform, scheduling, or group satisfaction. Fine: How about updates in new medications, management of hyponatremia, the unique challenges of women in medicine, managing acute ventilator issues, acute pain management, information technology, quality improvement, professionalism in the digital age, or listening to the latest in the management of Clostridium difficile from the world-renowned Dr. John Bartlett? All are tools in this year’s toolkit.

And this type of breadth means the annual meeting evolves with you. Early in my career, I reached for the clinical tools. Then it was practice development and management tools; now I tend to look for healthcare policy solutions. Suffice to say, whatever solution you are looking for, with nine tracks, eight pathways, seven pre-courses, three plenary sessions by healthcare luminaries, and two Research, Innovation, and Vignette sessions, HM12 has your tool.

How can you best access this trove of information? Here is some advice culled from my 10 years of attending SHM annual meetings.

They Won’t Leave A Light On For You Forever

Unless you’re Tom Bodett, I’d recommend you get a hotel room now. For my first annual meeting (which was also in San Diego), I registered late, found no hotel rooms in the city, and had to commute 30 minutes both ways. Not only is this inconvenient and costly (I had to rent a car), but it also takes you out of the action. You want to be on-site, especially after meeting hours, when a lot of the networking and fun happens.

Stay Out Late

OK, now that you have a room, don’t use it. Rooms are for sleeping. If you find yourself in your room not sleeping, then you are missing out on some of the richest aspects of the conference—meeting new people, catching up with colleagues you see only once a year, and bathing in the general excitement of being at a meeting with thousands of peers. This remains the most satisfying part of the annual meeting experience for me. It’s dinner with a colleague from another part of the country, coffee with a new acquaintance, or a drink with an old friend. It’s energizing, engaging, and reignites my passion for HM.

Sleep Is For Vacation

Staying with the hotel room theme, don’t sleep in. I realize San Diego in April can feel like a vacation, and truth be told, it should. However, you came to learn. It’s tempting to maximize pillow time instead of heading down to the first plenary session at 8 a.m.—after all, you stayed out late networking! Anyway, how interesting can it be? Very. Dr. Patrick Conway is going to lead off the meeting with a look at the implications of the Affordable Care Act for hospitalists. As a hospitalist and CMO of CMS, he should know. Come to this session, and so will you.

Declare a Major and a Minor

Remember college? Me, neither. But I do have a vague recollection of that kid-in-a-candy-store feeling of choice my freshman year. The rest is a blur of late nights, hungover Sundays, and weight gain. Just like the college course book, the HM12 agenda can be overwhelming. Choice is great, but how do you choose what to go to? Just like college, you need a plan. Spend time before the meeting charting your course. What do you want to learn? What knowledge gaps do you want to fill? Throw in something for fun. Peruse the website, print out or download the slide decks from the talks you are interested in, and have a plan to maximize your time in San Diego.

Divide and Conquer

Next, make a plan with your friends. Most attendees have at least one other group member attending the meeting. Don’t go to the same sessions. Why? You should share your findings with the rest of your group.

You’ll no doubt pick up a new method for patient handoffs, moving patients through the hospital more efficiently, creating an incentive plan, or developing a post-discharge clinic. Bring it home; share it; implement it.

Go to the RIV Sessions

“But wait,” you say, “I’m not a researcher.” Perhaps true, but you are a hospitalist. And this is the material that is coming down the pike. It’s the cool case you’ll encounter next month, the innovation that’ll help your patients avoid hospital infections, or the research that will inform the next VTE prophylaxis guideline.

Go Viral

Bring your business cards. And like a rhinovirus, give them to everyone. Entranced person next to you at the plenary? Card. New face at the Special Interest Forum for rural hospitalists? Card. Erudite-appearing character scanning the poster abstract on readmissions with you? Card. Bagel-versus-English-muffin-debating person in the breakfast line? Card.

The point is, don’t be shy. You are there to be part of the hospitalist movement—to learn, to share, to be part of the discussion, to help define our collective future. Do that. This isn’t the time to be a wallflower. Rather, say “hi” to the person next to you. Strike up a conversation; you never know where it may lead.

You Had Me At “Hello”

So tell your boss to “show me the money,” so that you, too, can utilize the HM12 toolkit. If he or she balks, tell them to “help me help you.” Because after attending the meeting, I’m confident that with a tear in your eye, you’ll sappily utter, “HM12, you complete me.”

Dr. Glasheen is physician editor of The Hospitalist.

I have a problem. OK, many problems. Marital discord, balky kids, bloated mortgage? No, fortunately, not those kinds of domestic problems—although I do struggle with reliably differentiating whites from darks. My biggest problem is work-related. And this isn’t new. Turns out, I have different problems at work every year. “Time to find a new job,” you say. Tell the boss to shove it? Produce an epic, Jerry Maguire-esque manifesto and ride off into the sunset with my goldfish and Renee Zellweger? Hmmm, Renee Zellweger…

No, no, that’s not it. Much more mundane, yet crucial, problems.

Problems like trying to sort out the implications of the impending value-based purchasing program—what does it mean for my group? How do I keep my hospitalist partners engaged, satisfied, and not burned out? How do I produce a schedule that emphasizes high-quality patient care, efficiency, and physician work-life balance? How can I reduce readmissions so my hospital administrator can go back to “administrating” someone other than me all day? What do I do with the perioperative beta blockade now that some of the original data have been called into question due to academic dishonesty? What does the Affordable Care Act really say, is it going stand up, and what does it mean for me, my patients, my salary, and my career?

These are all questions I am grappling with currently. They also are all questions that will be addressed at HM12, April 1-4 in San Diego. As such, I view the annual meeting as a kind of toolkit: Have a problem, reach into the HM12 toolkit, and pull out your solution. The beauty is its breadth. You might not care one iota about healthcare reform, scheduling, or group satisfaction. Fine: How about updates in new medications, management of hyponatremia, the unique challenges of women in medicine, managing acute ventilator issues, acute pain management, information technology, quality improvement, professionalism in the digital age, or listening to the latest in the management of Clostridium difficile from the world-renowned Dr. John Bartlett? All are tools in this year’s toolkit.

And this type of breadth means the annual meeting evolves with you. Early in my career, I reached for the clinical tools. Then it was practice development and management tools; now I tend to look for healthcare policy solutions. Suffice to say, whatever solution you are looking for, with nine tracks, eight pathways, seven pre-courses, three plenary sessions by healthcare luminaries, and two Research, Innovation, and Vignette sessions, HM12 has your tool.

How can you best access this trove of information? Here is some advice culled from my 10 years of attending SHM annual meetings.

They Won’t Leave A Light On For You Forever

Unless you’re Tom Bodett, I’d recommend you get a hotel room now. For my first annual meeting (which was also in San Diego), I registered late, found no hotel rooms in the city, and had to commute 30 minutes both ways. Not only is this inconvenient and costly (I had to rent a car), but it also takes you out of the action. You want to be on-site, especially after meeting hours, when a lot of the networking and fun happens.

Stay Out Late

OK, now that you have a room, don’t use it. Rooms are for sleeping. If you find yourself in your room not sleeping, then you are missing out on some of the richest aspects of the conference—meeting new people, catching up with colleagues you see only once a year, and bathing in the general excitement of being at a meeting with thousands of peers. This remains the most satisfying part of the annual meeting experience for me. It’s dinner with a colleague from another part of the country, coffee with a new acquaintance, or a drink with an old friend. It’s energizing, engaging, and reignites my passion for HM.

Sleep Is For Vacation

Staying with the hotel room theme, don’t sleep in. I realize San Diego in April can feel like a vacation, and truth be told, it should. However, you came to learn. It’s tempting to maximize pillow time instead of heading down to the first plenary session at 8 a.m.—after all, you stayed out late networking! Anyway, how interesting can it be? Very. Dr. Patrick Conway is going to lead off the meeting with a look at the implications of the Affordable Care Act for hospitalists. As a hospitalist and CMO of CMS, he should know. Come to this session, and so will you.

Declare a Major and a Minor

Remember college? Me, neither. But I do have a vague recollection of that kid-in-a-candy-store feeling of choice my freshman year. The rest is a blur of late nights, hungover Sundays, and weight gain. Just like the college course book, the HM12 agenda can be overwhelming. Choice is great, but how do you choose what to go to? Just like college, you need a plan. Spend time before the meeting charting your course. What do you want to learn? What knowledge gaps do you want to fill? Throw in something for fun. Peruse the website, print out or download the slide decks from the talks you are interested in, and have a plan to maximize your time in San Diego.

Divide and Conquer

Next, make a plan with your friends. Most attendees have at least one other group member attending the meeting. Don’t go to the same sessions. Why? You should share your findings with the rest of your group.

You’ll no doubt pick up a new method for patient handoffs, moving patients through the hospital more efficiently, creating an incentive plan, or developing a post-discharge clinic. Bring it home; share it; implement it.

Go to the RIV Sessions

“But wait,” you say, “I’m not a researcher.” Perhaps true, but you are a hospitalist. And this is the material that is coming down the pike. It’s the cool case you’ll encounter next month, the innovation that’ll help your patients avoid hospital infections, or the research that will inform the next VTE prophylaxis guideline.

Go Viral

Bring your business cards. And like a rhinovirus, give them to everyone. Entranced person next to you at the plenary? Card. New face at the Special Interest Forum for rural hospitalists? Card. Erudite-appearing character scanning the poster abstract on readmissions with you? Card. Bagel-versus-English-muffin-debating person in the breakfast line? Card.

The point is, don’t be shy. You are there to be part of the hospitalist movement—to learn, to share, to be part of the discussion, to help define our collective future. Do that. This isn’t the time to be a wallflower. Rather, say “hi” to the person next to you. Strike up a conversation; you never know where it may lead.

You Had Me At “Hello”

So tell your boss to “show me the money,” so that you, too, can utilize the HM12 toolkit. If he or she balks, tell them to “help me help you.” Because after attending the meeting, I’m confident that with a tear in your eye, you’ll sappily utter, “HM12, you complete me.”

Dr. Glasheen is physician editor of The Hospitalist.

I have a problem. OK, many problems. Marital discord, balky kids, bloated mortgage? No, fortunately, not those kinds of domestic problems—although I do struggle with reliably differentiating whites from darks. My biggest problem is work-related. And this isn’t new. Turns out, I have different problems at work every year. “Time to find a new job,” you say. Tell the boss to shove it? Produce an epic, Jerry Maguire-esque manifesto and ride off into the sunset with my goldfish and Renee Zellweger? Hmmm, Renee Zellweger…

No, no, that’s not it. Much more mundane, yet crucial, problems.

Problems like trying to sort out the implications of the impending value-based purchasing program—what does it mean for my group? How do I keep my hospitalist partners engaged, satisfied, and not burned out? How do I produce a schedule that emphasizes high-quality patient care, efficiency, and physician work-life balance? How can I reduce readmissions so my hospital administrator can go back to “administrating” someone other than me all day? What do I do with the perioperative beta blockade now that some of the original data have been called into question due to academic dishonesty? What does the Affordable Care Act really say, is it going stand up, and what does it mean for me, my patients, my salary, and my career?

These are all questions I am grappling with currently. They also are all questions that will be addressed at HM12, April 1-4 in San Diego. As such, I view the annual meeting as a kind of toolkit: Have a problem, reach into the HM12 toolkit, and pull out your solution. The beauty is its breadth. You might not care one iota about healthcare reform, scheduling, or group satisfaction. Fine: How about updates in new medications, management of hyponatremia, the unique challenges of women in medicine, managing acute ventilator issues, acute pain management, information technology, quality improvement, professionalism in the digital age, or listening to the latest in the management of Clostridium difficile from the world-renowned Dr. John Bartlett? All are tools in this year’s toolkit.

And this type of breadth means the annual meeting evolves with you. Early in my career, I reached for the clinical tools. Then it was practice development and management tools; now I tend to look for healthcare policy solutions. Suffice to say, whatever solution you are looking for, with nine tracks, eight pathways, seven pre-courses, three plenary sessions by healthcare luminaries, and two Research, Innovation, and Vignette sessions, HM12 has your tool.

How can you best access this trove of information? Here is some advice culled from my 10 years of attending SHM annual meetings.

They Won’t Leave A Light On For You Forever

Unless you’re Tom Bodett, I’d recommend you get a hotel room now. For my first annual meeting (which was also in San Diego), I registered late, found no hotel rooms in the city, and had to commute 30 minutes both ways. Not only is this inconvenient and costly (I had to rent a car), but it also takes you out of the action. You want to be on-site, especially after meeting hours, when a lot of the networking and fun happens.

Stay Out Late

OK, now that you have a room, don’t use it. Rooms are for sleeping. If you find yourself in your room not sleeping, then you are missing out on some of the richest aspects of the conference—meeting new people, catching up with colleagues you see only once a year, and bathing in the general excitement of being at a meeting with thousands of peers. This remains the most satisfying part of the annual meeting experience for me. It’s dinner with a colleague from another part of the country, coffee with a new acquaintance, or a drink with an old friend. It’s energizing, engaging, and reignites my passion for HM.

Sleep Is For Vacation

Staying with the hotel room theme, don’t sleep in. I realize San Diego in April can feel like a vacation, and truth be told, it should. However, you came to learn. It’s tempting to maximize pillow time instead of heading down to the first plenary session at 8 a.m.—after all, you stayed out late networking! Anyway, how interesting can it be? Very. Dr. Patrick Conway is going to lead off the meeting with a look at the implications of the Affordable Care Act for hospitalists. As a hospitalist and CMO of CMS, he should know. Come to this session, and so will you.

Declare a Major and a Minor

Remember college? Me, neither. But I do have a vague recollection of that kid-in-a-candy-store feeling of choice my freshman year. The rest is a blur of late nights, hungover Sundays, and weight gain. Just like the college course book, the HM12 agenda can be overwhelming. Choice is great, but how do you choose what to go to? Just like college, you need a plan. Spend time before the meeting charting your course. What do you want to learn? What knowledge gaps do you want to fill? Throw in something for fun. Peruse the website, print out or download the slide decks from the talks you are interested in, and have a plan to maximize your time in San Diego.

Divide and Conquer

Next, make a plan with your friends. Most attendees have at least one other group member attending the meeting. Don’t go to the same sessions. Why? You should share your findings with the rest of your group.

You’ll no doubt pick up a new method for patient handoffs, moving patients through the hospital more efficiently, creating an incentive plan, or developing a post-discharge clinic. Bring it home; share it; implement it.

Go to the RIV Sessions

“But wait,” you say, “I’m not a researcher.” Perhaps true, but you are a hospitalist. And this is the material that is coming down the pike. It’s the cool case you’ll encounter next month, the innovation that’ll help your patients avoid hospital infections, or the research that will inform the next VTE prophylaxis guideline.

Go Viral

Bring your business cards. And like a rhinovirus, give them to everyone. Entranced person next to you at the plenary? Card. New face at the Special Interest Forum for rural hospitalists? Card. Erudite-appearing character scanning the poster abstract on readmissions with you? Card. Bagel-versus-English-muffin-debating person in the breakfast line? Card.

The point is, don’t be shy. You are there to be part of the hospitalist movement—to learn, to share, to be part of the discussion, to help define our collective future. Do that. This isn’t the time to be a wallflower. Rather, say “hi” to the person next to you. Strike up a conversation; you never know where it may lead.

You Had Me At “Hello”

So tell your boss to “show me the money,” so that you, too, can utilize the HM12 toolkit. If he or she balks, tell them to “help me help you.” Because after attending the meeting, I’m confident that with a tear in your eye, you’ll sappily utter, “HM12, you complete me.”

Dr. Glasheen is physician editor of The Hospitalist.

Should or must? That was the sticking point. After months of hard work, it had come down to this.

In a sense, these words are synonyms. In reality, they are words, and they are worlds apart.

This discourse occurred within a task force I am working with to clinically transform our medical center—that is, making an institutional commitment to quality improvement (QI), patient safety, and clinical efficiency. The effort, in part, is driven by value-based purchasing, public reporting, payment reform, and the like. But mostly it’s being driven by the fundamental premise of doing right by our patients.

We all agreed that we have to change, that it will be hard and even what types of change are needed. The struggle came down to “should” or “must.”

I’ve used several columns imploring hospitalists to lead the quality evolution. I’ve spent less time explaining how to do this. It’s one thing to say, “Hospitalists are perfectly positioned to fundamentally change the quality, safety, and efficiency of hospital care.” It’s another to fundamentally change the quality, safety, and efficiency of hospital care. So, with the disclaimer that my HM group’s efforts to improve quality have only begun to scratch the surface of success, here are some of the lessons I’ve learned.

Start Urgently

Change is very hard for hominids. We favor the devil we know. Therefore, change requires establishing a sense of urgency for the change. Conceptually, QI is enticing—until it gets hard. Then the inevitable changes in workflow start to feel like a lot of work, often without obvious or immediate benefit.

As such, people have to believe there is a problem before they can muster the energy it takes to change. I’d submit to you that the problem with patient safety and quality in healthcare is that most of us don’t think there is a problem.

It takes someone to show us there is a problem before we can change. If you cannot create this sense of urgency for change, you should stop. Don’t continue to try to lead change. You will fail. Guaranteed.

Thus, the most important step in transformation toward quality is convincing people of the need to change. This is hard to do and requires our second step.

Leading The Ship

Leadership. By which I’m not talking about the person in charge, the autocrat, the boss. Leadership is getting people to go somewhere they otherwise wouldn’t have gone. A boss can do this, but most often this is done by the people in the trenches, by front-line people who see a problem and aspire for change, by people like you.

Quality needs leadership; we are its leaders.

20/20 Vision

A vision is the end game; it’s the finish line, that thing we are all striving for. It’s a big, inspirational, audacious goal that we can all rally behind. It’s things like “zero harm” or “no avoidable errors.”

The vision should not be confused with the plan. Plans are great. But plans that don’t tie back to a vision are destined to fail. Why? Because change is hard, and as soon as a plan (e.g. call PCPs on each discharge, reconcile 24 medications in a demented patient) gets hard, people stop doing it.

Show them, however, how the plan (often something they don’t want to do) ties back to the vision (something they want to do), and people are more likely to follow. I’ll put in the extra effort for medication reconciliation (plan) if I believe there is a problem (sense of urgency) and that this plan helps achieve the vision (no avoidable errors).

Have Patience

Administrators rightly want solutions yesterday. But clinical transformation of this type takes time. We will not unfurl the “Mission Accomplished” banner in three months. This will take years, probably a decade. For two reasons:

1. This requires culture change, which takes time.
2. We need bench strength.

A focus on quality cannot be accomplished with five or even 50 people working on this. Rather, it requires 500 to 5,000 people—indeed, the entire organization. It takes time to change the culture, engage the people, and make the mistakes that success requires.

Make It Easier To Do The Right Thing

We have to remove the barriers that limit success. This means not asking high-paid physicians to do chart abstraction, analyze data, and coordinate meetings—support staff should perform these tasks.

We also need institution- and provider-level data. Without valid and timely provider-level data, it is exceptionally difficult to create the needed sense of urgency for change. Show me I’m not meeting my expectations, and I’ll do what it takes to change. Leave me to believe that I’m the best doctor in the world—as we all are, of course—and I have no impetus to improve.

Success requires the infrastructure that makes it harder to do the wrong thing and easier to do the right thing.

Show Me The Money

Quality cannot be an unfunded mandate. Infrastructure needs to be built, support staff hired, and physician time protected to devote to this work.

That being said, I’d submit that if after five years an institution doesn’t see a return on investment (in cost avoidance and increased revenue) of at least 5:1 for every dollar spent, then either you’ve built it wrong or we are all misreading the tea leaves in terms of value-based purchasing. I wouldn’t bet on the latter.

Partner With Your Partners

Medicine is a team sport. True success hinges on a multiprofessional approach. Our success will be directly proportional to the degree to which we engage our clinical-care partners.

This is a less autonomous way of thinking than most of us were taught. We studied alone, took tests alone, saw patients alone. To engage nurses, therapists, pharmacists, and hospital administrators in a dynamic team is outside most of our comfort zones.

Culturing Change

We cannot mend our broken system until we begin to do things differently. Success demands that we work in teams, partner with our hospital administrators, and agree to be measured. We must better communicate with other providers, reduce variability, forgo some autonomy, and shift from physician- to patient-centric care models. This will be hard. This will be uncomfortable. This will require tough decisions.

Failure or Success

Which brings me back to our task force’s definitional divide. The issue was how strongly we push physician involvement in our quality and safety program. Do we encourage all doctors to participate (doctors “should”), or do we require all doctors to participate (doctors “must”)? The task force was divided.

On the one hand, it’s hard to mandate involvement. This would be a huge physician commitment. It would take a lot of training, time, effort, and money. There would be innumerable challenges, perhaps physician turnover.

Was this a battle worth fighting? The difference between “should” and “must” is quite small. They say nearly the same thing. Except they don’t. “Should” says it’s optional; “must” is a mandate. “Should” says it’d be nice if you’d do this; “must” states it’s an institutional priority.

This distinction is not small. It is the difference between indifference and commitment, between our present and our future, between failure and success.

Dr. Glasheen is physician editor of The Hospitalist.

For more tips on getting quality programs started at your hospital, visit www.hospitalmedicine.org/thecenter.

Should or must? That was the sticking point. After months of hard work, it had come down to this.

In a sense, these words are synonyms. In reality, they are words, and they are worlds apart.

This discourse occurred within a task force I am working with to clinically transform our medical center—that is, making an institutional commitment to quality improvement (QI), patient safety, and clinical efficiency. The effort, in part, is driven by value-based purchasing, public reporting, payment reform, and the like. But mostly it’s being driven by the fundamental premise of doing right by our patients.

We all agreed that we have to change, that it will be hard and even what types of change are needed. The struggle came down to “should” or “must.”

I’ve used several columns imploring hospitalists to lead the quality evolution. I’ve spent less time explaining how to do this. It’s one thing to say, “Hospitalists are perfectly positioned to fundamentally change the quality, safety, and efficiency of hospital care.” It’s another to fundamentally change the quality, safety, and efficiency of hospital care. So, with the disclaimer that my HM group’s efforts to improve quality have only begun to scratch the surface of success, here are some of the lessons I’ve learned.

Start Urgently

Change is very hard for hominids. We favor the devil we know. Therefore, change requires establishing a sense of urgency for the change. Conceptually, QI is enticing—until it gets hard. Then the inevitable changes in workflow start to feel like a lot of work, often without obvious or immediate benefit.

As such, people have to believe there is a problem before they can muster the energy it takes to change. I’d submit to you that the problem with patient safety and quality in healthcare is that most of us don’t think there is a problem.

It takes someone to show us there is a problem before we can change. If you cannot create this sense of urgency for change, you should stop. Don’t continue to try to lead change. You will fail. Guaranteed.

Thus, the most important step in transformation toward quality is convincing people of the need to change. This is hard to do and requires our second step.

Leading The Ship

Leadership. By which I’m not talking about the person in charge, the autocrat, the boss. Leadership is getting people to go somewhere they otherwise wouldn’t have gone. A boss can do this, but most often this is done by the people in the trenches, by front-line people who see a problem and aspire for change, by people like you.

Quality needs leadership; we are its leaders.

20/20 Vision

A vision is the end game; it’s the finish line, that thing we are all striving for. It’s a big, inspirational, audacious goal that we can all rally behind. It’s things like “zero harm” or “no avoidable errors.”

The vision should not be confused with the plan. Plans are great. But plans that don’t tie back to a vision are destined to fail. Why? Because change is hard, and as soon as a plan (e.g. call PCPs on each discharge, reconcile 24 medications in a demented patient) gets hard, people stop doing it.

Show them, however, how the plan (often something they don’t want to do) ties back to the vision (something they want to do), and people are more likely to follow. I’ll put in the extra effort for medication reconciliation (plan) if I believe there is a problem (sense of urgency) and that this plan helps achieve the vision (no avoidable errors).

Have Patience

Administrators rightly want solutions yesterday. But clinical transformation of this type takes time. We will not unfurl the “Mission Accomplished” banner in three months. This will take years, probably a decade. For two reasons:

1. This requires culture change, which takes time.
2. We need bench strength.

A focus on quality cannot be accomplished with five or even 50 people working on this. Rather, it requires 500 to 5,000 people—indeed, the entire organization. It takes time to change the culture, engage the people, and make the mistakes that success requires.

Make It Easier To Do The Right Thing

We have to remove the barriers that limit success. This means not asking high-paid physicians to do chart abstraction, analyze data, and coordinate meetings—support staff should perform these tasks.

We also need institution- and provider-level data. Without valid and timely provider-level data, it is exceptionally difficult to create the needed sense of urgency for change. Show me I’m not meeting my expectations, and I’ll do what it takes to change. Leave me to believe that I’m the best doctor in the world—as we all are, of course—and I have no impetus to improve.

Success requires the infrastructure that makes it harder to do the wrong thing and easier to do the right thing.

Show Me The Money

Quality cannot be an unfunded mandate. Infrastructure needs to be built, support staff hired, and physician time protected to devote to this work.

That being said, I’d submit that if after five years an institution doesn’t see a return on investment (in cost avoidance and increased revenue) of at least 5:1 for every dollar spent, then either you’ve built it wrong or we are all misreading the tea leaves in terms of value-based purchasing. I wouldn’t bet on the latter.

Partner With Your Partners

Medicine is a team sport. True success hinges on a multiprofessional approach. Our success will be directly proportional to the degree to which we engage our clinical-care partners.

This is a less autonomous way of thinking than most of us were taught. We studied alone, took tests alone, saw patients alone. To engage nurses, therapists, pharmacists, and hospital administrators in a dynamic team is outside most of our comfort zones.

Culturing Change

We cannot mend our broken system until we begin to do things differently. Success demands that we work in teams, partner with our hospital administrators, and agree to be measured. We must better communicate with other providers, reduce variability, forgo some autonomy, and shift from physician- to patient-centric care models. This will be hard. This will be uncomfortable. This will require tough decisions.

Failure or Success

Which brings me back to our task force’s definitional divide. The issue was how strongly we push physician involvement in our quality and safety program. Do we encourage all doctors to participate (doctors “should”), or do we require all doctors to participate (doctors “must”)? The task force was divided.

On the one hand, it’s hard to mandate involvement. This would be a huge physician commitment. It would take a lot of training, time, effort, and money. There would be innumerable challenges, perhaps physician turnover.

Was this a battle worth fighting? The difference between “should” and “must” is quite small. They say nearly the same thing. Except they don’t. “Should” says it’s optional; “must” is a mandate. “Should” says it’d be nice if you’d do this; “must” states it’s an institutional priority.

This distinction is not small. It is the difference between indifference and commitment, between our present and our future, between failure and success.

Dr. Glasheen is physician editor of The Hospitalist.

For more tips on getting quality programs started at your hospital, visit www.hospitalmedicine.org/thecenter.

Should or must? That was the sticking point. After months of hard work, it had come down to this.

In a sense, these words are synonyms. In reality, they are words, and they are worlds apart.

This discourse occurred within a task force I am working with to clinically transform our medical center—that is, making an institutional commitment to quality improvement (QI), patient safety, and clinical efficiency. The effort, in part, is driven by value-based purchasing, public reporting, payment reform, and the like. But mostly it’s being driven by the fundamental premise of doing right by our patients.

We all agreed that we have to change, that it will be hard and even what types of change are needed. The struggle came down to “should” or “must.”

I’ve used several columns imploring hospitalists to lead the quality evolution. I’ve spent less time explaining how to do this. It’s one thing to say, “Hospitalists are perfectly positioned to fundamentally change the quality, safety, and efficiency of hospital care.” It’s another to fundamentally change the quality, safety, and efficiency of hospital care. So, with the disclaimer that my HM group’s efforts to improve quality have only begun to scratch the surface of success, here are some of the lessons I’ve learned.

Start Urgently

Change is very hard for hominids. We favor the devil we know. Therefore, change requires establishing a sense of urgency for the change. Conceptually, QI is enticing—until it gets hard. Then the inevitable changes in workflow start to feel like a lot of work, often without obvious or immediate benefit.

As such, people have to believe there is a problem before they can muster the energy it takes to change. I’d submit to you that the problem with patient safety and quality in healthcare is that most of us don’t think there is a problem.

It takes someone to show us there is a problem before we can change. If you cannot create this sense of urgency for change, you should stop. Don’t continue to try to lead change. You will fail. Guaranteed.

Thus, the most important step in transformation toward quality is convincing people of the need to change. This is hard to do and requires our second step.

Leading The Ship

Leadership. By which I’m not talking about the person in charge, the autocrat, the boss. Leadership is getting people to go somewhere they otherwise wouldn’t have gone. A boss can do this, but most often this is done by the people in the trenches, by front-line people who see a problem and aspire for change, by people like you.

Quality needs leadership; we are its leaders.

20/20 Vision

A vision is the end game; it’s the finish line, that thing we are all striving for. It’s a big, inspirational, audacious goal that we can all rally behind. It’s things like “zero harm” or “no avoidable errors.”

The vision should not be confused with the plan. Plans are great. But plans that don’t tie back to a vision are destined to fail. Why? Because change is hard, and as soon as a plan (e.g. call PCPs on each discharge, reconcile 24 medications in a demented patient) gets hard, people stop doing it.

Show them, however, how the plan (often something they don’t want to do) ties back to the vision (something they want to do), and people are more likely to follow. I’ll put in the extra effort for medication reconciliation (plan) if I believe there is a problem (sense of urgency) and that this plan helps achieve the vision (no avoidable errors).

Have Patience

Administrators rightly want solutions yesterday. But clinical transformation of this type takes time. We will not unfurl the “Mission Accomplished” banner in three months. This will take years, probably a decade. For two reasons:

1. This requires culture change, which takes time.
2. We need bench strength.

A focus on quality cannot be accomplished with five or even 50 people working on this. Rather, it requires 500 to 5,000 people—indeed, the entire organization. It takes time to change the culture, engage the people, and make the mistakes that success requires.

Make It Easier To Do The Right Thing

We have to remove the barriers that limit success. This means not asking high-paid physicians to do chart abstraction, analyze data, and coordinate meetings—support staff should perform these tasks.

We also need institution- and provider-level data. Without valid and timely provider-level data, it is exceptionally difficult to create the needed sense of urgency for change. Show me I’m not meeting my expectations, and I’ll do what it takes to change. Leave me to believe that I’m the best doctor in the world—as we all are, of course—and I have no impetus to improve.

Success requires the infrastructure that makes it harder to do the wrong thing and easier to do the right thing.

Show Me The Money

Quality cannot be an unfunded mandate. Infrastructure needs to be built, support staff hired, and physician time protected to devote to this work.

That being said, I’d submit that if after five years an institution doesn’t see a return on investment (in cost avoidance and increased revenue) of at least 5:1 for every dollar spent, then either you’ve built it wrong or we are all misreading the tea leaves in terms of value-based purchasing. I wouldn’t bet on the latter.

Partner With Your Partners

Medicine is a team sport. True success hinges on a multiprofessional approach. Our success will be directly proportional to the degree to which we engage our clinical-care partners.

This is a less autonomous way of thinking than most of us were taught. We studied alone, took tests alone, saw patients alone. To engage nurses, therapists, pharmacists, and hospital administrators in a dynamic team is outside most of our comfort zones.

Culturing Change

We cannot mend our broken system until we begin to do things differently. Success demands that we work in teams, partner with our hospital administrators, and agree to be measured. We must better communicate with other providers, reduce variability, forgo some autonomy, and shift from physician- to patient-centric care models. This will be hard. This will be uncomfortable. This will require tough decisions.

Failure or Success

Which brings me back to our task force’s definitional divide. The issue was how strongly we push physician involvement in our quality and safety program. Do we encourage all doctors to participate (doctors “should”), or do we require all doctors to participate (doctors “must”)? The task force was divided.

On the one hand, it’s hard to mandate involvement. This would be a huge physician commitment. It would take a lot of training, time, effort, and money. There would be innumerable challenges, perhaps physician turnover.

Was this a battle worth fighting? The difference between “should” and “must” is quite small. They say nearly the same thing. Except they don’t. “Should” says it’s optional; “must” is a mandate. “Should” says it’d be nice if you’d do this; “must” states it’s an institutional priority.

This distinction is not small. It is the difference between indifference and commitment, between our present and our future, between failure and success.

Dr. Glasheen is physician editor of The Hospitalist.

For more tips on getting quality programs started at your hospital, visit www.hospitalmedicine.org/thecenter.

It’s that time of year again. A new year is upon us. It’s resolution time.

I must admit, somewhat sheepishly, that I am a bit of “resolver.” What can I say? I like to resolve. I like to think about resolutions. I like to plan resolutions. I like to regale my uninterested wife with my resolutions. And I am, in fact, actually quite good at all phases of resolving, with one small exception—the follow-through.

You see, while I love to plan changes in my life, I’m horrible at making changes in my life. There’s nothing too shocking about that, I suppose. Most people fail when change is required. What is interesting, though, is that years of failure have yet to imbue me with the sense to stop resolving. I mean, how many times can a man fail at resolutions before he stumbles upon a resolution to stop resolving—a resolution I’d surely fail at?

But what are perhaps even more interesting are the things I’ve apparently resolved to do. I say “apparently” because not only do I typically not remember making the resolutions, but most often I also can’t even fathom why I’d resolve such things in the first place. But clearly I do. In fact, every year, I commit to about 10-20 resolutions. I actually write them down, threaten to make my wife read them, then stow them safely in my desk drawer, only to unearth them a year later to discover that I actually resolved to write a children’s book. True story; I just reviewed my resolutions from last year. I don’t remember why I put that on the list. But I did. And, of course, I failed—but I did, in fact, read a children’s book. Maybe that’s what I meant.

Over the years I’ve also resolved to make a hole-in-one, get better hair, and read War and Peace (on the toilet, during medical school). Fail, fail, and fail. The last one’s a great example of good intentions and no follow-through. Driven by the numerology (1,296 pages+1,296 days of medical school, excluding the last semester, of course, as most of us did=one page per day!) and the symbolism (medical school+grueling+war=challenging, long, grueling book about war) of the goal, I was ultimately undone by an inability to reliably differentiate a Bezukhov from a Bolkonsky, and constipation.

I bring this all up because it is time again for New Year’s resolutions. So here, in no particular order, are my 2012 resolutions.

Oh, That’s How Full Feels!

In 2012, I resolve to finally have a fully staffed HM group. From our group’s origins in 2003 to our current 30-member group, we have been intermittently understaffed to various degrees—a feeling I know most of you have experienced. For a couple of years we were fully staffed, but recent hospital expansions again place us at risk of being understaffed. As most of you know, it is exceedingly difficult to move the clinical, quality, and efficiency goals of a group forward without enough boots on the ground. So, if you’re in the market, the skiing in Colorado can’t be beat!

Appreciate VBP

I resolve to position our hospitalist group for the coming value-based purchasing world. We all know that the future belongs to those who can provide fundamental value—that is, higher-quality care at lower cost. This has been HM’s mantra the past decade. 2012 is the year I resolve to see our group fully realize this.

Leave the Cave

I resolve to (really) learn how to use Epic. We implemented our new Epic electronic health record in 2011. I’m a big proponent, but also a Luddite. I tinker around the edges of what is a truly powerful tool in advancing clinical care. I resolve to move past casual to highly functional user.

Make “10” Perfect

I resolve to figure out this new ICD-10 system. OK, technically it’s not “new.” It’s been complete since 1992 and in use in many countries for the better part of a decade. This is not a simple update of the ICD-9 system; rather, this is an entire overhaul that adds two more digits to the system. This takes the number of possible codes from 13,000 (ICD-9) to 68,000 (ICD-10). This allows for much more specificity and laterality—that is, you could have cellulitis of the right or left foot.

These changes are more than just job security for coders. The issue monetizes as payors decide not to pay for readmissions. Consider a patient who had a right-foot cellulitis, only to be admitted two weeks later with a left-foot cellulitis. ICD-9 does not have laterality, such that both stays would have the same code and the second admit could be denied as a 30-day readmission.

Twitter With Excitement

I resolve to figure out social media. I must admit that this is a red-alert, high-risk-of-failure resolution, partly because I don’t Facebook, tweet, or blog; heck, I’m not even LinkedIn! Additionally, I don’t have any friends. And finally, I just don’t get it. Then again, I didn’t get “The Simpsons” when they first came out. D’oh!

Get Hipper

And I resolve to re-enter the pop culture world in general. My social and cultural life came to a screeching halt near midnight on Sept. 29, 2007: One moment I was innocently watching the Colorado Rockies battle into their first playoffs in 12 years, and the next I was blasted onto a four-year hyper-blur of crying, spoon-feeding, and diaper-changing—for the non-parent readers, I’m describing child-rearing, not residency training, which is admittedly often marked by these same mileposts. Now 4 and 2 years old, my kiddos have finally reached the stages of self-care that allow for my gradual re-entry into the outside world.

As such, I resolve to go to a movie (in the theater) again. The last two movies we saw in the theatre in 2007 were chosen by my pregnant wife and contained an uncomfortable subliminal theme—Knocked Up (pregnant woman hates impregnating sloth of a man), Juno (pregnant woman has love-hate relationship with pasty, impregnating nerd in tight gym shorts).

I’m also interested to see what’s on TV and on the radio. When I last turned off the cathodes, “Lost” was big; ditto “The Sopranos.” And in a clearly ill-fated second season, “Dancing with the Stars” was well on its way to its undeniable cancellation. Musically, Britney was shaving her head and Jordin Sparks was edging out Sanjaya’s faux-hawk on “Idol.”

I’m also looking forward to learning what a Kardashian is (a sweater?), explaining the strange pull toward vampire romances, and discovering the difference between a Pippa and a Snooki. Should be fun. I just hope I don’t catch “Bieber Fever.”

Aspire To “Be The Cup”

Finally, in 2012, I resolve to live up to the coffee cup—you know, the Father’s Day 2011 gift emblazoned with “World’s Best Dad.” I’m sure you all feel this in your own way—that constant tension between work and life. In 2011, work won a few too many of the tug-o’-wars. Too many missed gymnastics lessons, soccer practices, parent events at daycare, and late dinners. 2012 will be different.

I resolve to teach my son the art of hitting a curveball (even if it’s off a tee) and my daughter her letters and numbers. The dogs will get more tennis balls, the wife fewer resolutions to review.

In fact, this year is going to be totally different. This is the year my to-do list doesn’t once again end as an “undid list.” This is the year I will accomplish my resolutions … not just one or two, but all of my resolutions.

And I might just write a children’s book for good measure.

Dr. Glasheen is The Hospitalist’s physician editor.

It’s that time of year again. A new year is upon us. It’s resolution time.

I must admit, somewhat sheepishly, that I am a bit of “resolver.” What can I say? I like to resolve. I like to think about resolutions. I like to plan resolutions. I like to regale my uninterested wife with my resolutions. And I am, in fact, actually quite good at all phases of resolving, with one small exception—the follow-through.

You see, while I love to plan changes in my life, I’m horrible at making changes in my life. There’s nothing too shocking about that, I suppose. Most people fail when change is required. What is interesting, though, is that years of failure have yet to imbue me with the sense to stop resolving. I mean, how many times can a man fail at resolutions before he stumbles upon a resolution to stop resolving—a resolution I’d surely fail at?

But what are perhaps even more interesting are the things I’ve apparently resolved to do. I say “apparently” because not only do I typically not remember making the resolutions, but most often I also can’t even fathom why I’d resolve such things in the first place. But clearly I do. In fact, every year, I commit to about 10-20 resolutions. I actually write them down, threaten to make my wife read them, then stow them safely in my desk drawer, only to unearth them a year later to discover that I actually resolved to write a children’s book. True story; I just reviewed my resolutions from last year. I don’t remember why I put that on the list. But I did. And, of course, I failed—but I did, in fact, read a children’s book. Maybe that’s what I meant.

Over the years I’ve also resolved to make a hole-in-one, get better hair, and read War and Peace (on the toilet, during medical school). Fail, fail, and fail. The last one’s a great example of good intentions and no follow-through. Driven by the numerology (1,296 pages+1,296 days of medical school, excluding the last semester, of course, as most of us did=one page per day!) and the symbolism (medical school+grueling+war=challenging, long, grueling book about war) of the goal, I was ultimately undone by an inability to reliably differentiate a Bezukhov from a Bolkonsky, and constipation.

I bring this all up because it is time again for New Year’s resolutions. So here, in no particular order, are my 2012 resolutions.

Oh, That’s How Full Feels!

In 2012, I resolve to finally have a fully staffed HM group. From our group’s origins in 2003 to our current 30-member group, we have been intermittently understaffed to various degrees—a feeling I know most of you have experienced. For a couple of years we were fully staffed, but recent hospital expansions again place us at risk of being understaffed. As most of you know, it is exceedingly difficult to move the clinical, quality, and efficiency goals of a group forward without enough boots on the ground. So, if you’re in the market, the skiing in Colorado can’t be beat!

Appreciate VBP

I resolve to position our hospitalist group for the coming value-based purchasing world. We all know that the future belongs to those who can provide fundamental value—that is, higher-quality care at lower cost. This has been HM’s mantra the past decade. 2012 is the year I resolve to see our group fully realize this.

Leave the Cave

I resolve to (really) learn how to use Epic. We implemented our new Epic electronic health record in 2011. I’m a big proponent, but also a Luddite. I tinker around the edges of what is a truly powerful tool in advancing clinical care. I resolve to move past casual to highly functional user.

Make “10” Perfect

I resolve to figure out this new ICD-10 system. OK, technically it’s not “new.” It’s been complete since 1992 and in use in many countries for the better part of a decade. This is not a simple update of the ICD-9 system; rather, this is an entire overhaul that adds two more digits to the system. This takes the number of possible codes from 13,000 (ICD-9) to 68,000 (ICD-10). This allows for much more specificity and laterality—that is, you could have cellulitis of the right or left foot.

These changes are more than just job security for coders. The issue monetizes as payors decide not to pay for readmissions. Consider a patient who had a right-foot cellulitis, only to be admitted two weeks later with a left-foot cellulitis. ICD-9 does not have laterality, such that both stays would have the same code and the second admit could be denied as a 30-day readmission.

Twitter With Excitement

I resolve to figure out social media. I must admit that this is a red-alert, high-risk-of-failure resolution, partly because I don’t Facebook, tweet, or blog; heck, I’m not even LinkedIn! Additionally, I don’t have any friends. And finally, I just don’t get it. Then again, I didn’t get “The Simpsons” when they first came out. D’oh!

Get Hipper

And I resolve to re-enter the pop culture world in general. My social and cultural life came to a screeching halt near midnight on Sept. 29, 2007: One moment I was innocently watching the Colorado Rockies battle into their first playoffs in 12 years, and the next I was blasted onto a four-year hyper-blur of crying, spoon-feeding, and diaper-changing—for the non-parent readers, I’m describing child-rearing, not residency training, which is admittedly often marked by these same mileposts. Now 4 and 2 years old, my kiddos have finally reached the stages of self-care that allow for my gradual re-entry into the outside world.

As such, I resolve to go to a movie (in the theater) again. The last two movies we saw in the theatre in 2007 were chosen by my pregnant wife and contained an uncomfortable subliminal theme—Knocked Up (pregnant woman hates impregnating sloth of a man), Juno (pregnant woman has love-hate relationship with pasty, impregnating nerd in tight gym shorts).

I’m also interested to see what’s on TV and on the radio. When I last turned off the cathodes, “Lost” was big; ditto “The Sopranos.” And in a clearly ill-fated second season, “Dancing with the Stars” was well on its way to its undeniable cancellation. Musically, Britney was shaving her head and Jordin Sparks was edging out Sanjaya’s faux-hawk on “Idol.”

I’m also looking forward to learning what a Kardashian is (a sweater?), explaining the strange pull toward vampire romances, and discovering the difference between a Pippa and a Snooki. Should be fun. I just hope I don’t catch “Bieber Fever.”

Aspire To “Be The Cup”

Finally, in 2012, I resolve to live up to the coffee cup—you know, the Father’s Day 2011 gift emblazoned with “World’s Best Dad.” I’m sure you all feel this in your own way—that constant tension between work and life. In 2011, work won a few too many of the tug-o’-wars. Too many missed gymnastics lessons, soccer practices, parent events at daycare, and late dinners. 2012 will be different.

I resolve to teach my son the art of hitting a curveball (even if it’s off a tee) and my daughter her letters and numbers. The dogs will get more tennis balls, the wife fewer resolutions to review.

In fact, this year is going to be totally different. This is the year my to-do list doesn’t once again end as an “undid list.” This is the year I will accomplish my resolutions … not just one or two, but all of my resolutions.

And I might just write a children’s book for good measure.

Dr. Glasheen is The Hospitalist’s physician editor.

It’s that time of year again. A new year is upon us. It’s resolution time.

I must admit, somewhat sheepishly, that I am a bit of “resolver.” What can I say? I like to resolve. I like to think about resolutions. I like to plan resolutions. I like to regale my uninterested wife with my resolutions. And I am, in fact, actually quite good at all phases of resolving, with one small exception—the follow-through.

You see, while I love to plan changes in my life, I’m horrible at making changes in my life. There’s nothing too shocking about that, I suppose. Most people fail when change is required. What is interesting, though, is that years of failure have yet to imbue me with the sense to stop resolving. I mean, how many times can a man fail at resolutions before he stumbles upon a resolution to stop resolving—a resolution I’d surely fail at?

But what are perhaps even more interesting are the things I’ve apparently resolved to do. I say “apparently” because not only do I typically not remember making the resolutions, but most often I also can’t even fathom why I’d resolve such things in the first place. But clearly I do. In fact, every year, I commit to about 10-20 resolutions. I actually write them down, threaten to make my wife read them, then stow them safely in my desk drawer, only to unearth them a year later to discover that I actually resolved to write a children’s book. True story; I just reviewed my resolutions from last year. I don’t remember why I put that on the list. But I did. And, of course, I failed—but I did, in fact, read a children’s book. Maybe that’s what I meant.

Over the years I’ve also resolved to make a hole-in-one, get better hair, and read War and Peace (on the toilet, during medical school). Fail, fail, and fail. The last one’s a great example of good intentions and no follow-through. Driven by the numerology (1,296 pages+1,296 days of medical school, excluding the last semester, of course, as most of us did=one page per day!) and the symbolism (medical school+grueling+war=challenging, long, grueling book about war) of the goal, I was ultimately undone by an inability to reliably differentiate a Bezukhov from a Bolkonsky, and constipation.

I bring this all up because it is time again for New Year’s resolutions. So here, in no particular order, are my 2012 resolutions.

Oh, That’s How Full Feels!

In 2012, I resolve to finally have a fully staffed HM group. From our group’s origins in 2003 to our current 30-member group, we have been intermittently understaffed to various degrees—a feeling I know most of you have experienced. For a couple of years we were fully staffed, but recent hospital expansions again place us at risk of being understaffed. As most of you know, it is exceedingly difficult to move the clinical, quality, and efficiency goals of a group forward without enough boots on the ground. So, if you’re in the market, the skiing in Colorado can’t be beat!

Appreciate VBP

I resolve to position our hospitalist group for the coming value-based purchasing world. We all know that the future belongs to those who can provide fundamental value—that is, higher-quality care at lower cost. This has been HM’s mantra the past decade. 2012 is the year I resolve to see our group fully realize this.

Leave the Cave

I resolve to (really) learn how to use Epic. We implemented our new Epic electronic health record in 2011. I’m a big proponent, but also a Luddite. I tinker around the edges of what is a truly powerful tool in advancing clinical care. I resolve to move past casual to highly functional user.

Make “10” Perfect

I resolve to figure out this new ICD-10 system. OK, technically it’s not “new.” It’s been complete since 1992 and in use in many countries for the better part of a decade. This is not a simple update of the ICD-9 system; rather, this is an entire overhaul that adds two more digits to the system. This takes the number of possible codes from 13,000 (ICD-9) to 68,000 (ICD-10). This allows for much more specificity and laterality—that is, you could have cellulitis of the right or left foot.

These changes are more than just job security for coders. The issue monetizes as payors decide not to pay for readmissions. Consider a patient who had a right-foot cellulitis, only to be admitted two weeks later with a left-foot cellulitis. ICD-9 does not have laterality, such that both stays would have the same code and the second admit could be denied as a 30-day readmission.

Twitter With Excitement

I resolve to figure out social media. I must admit that this is a red-alert, high-risk-of-failure resolution, partly because I don’t Facebook, tweet, or blog; heck, I’m not even LinkedIn! Additionally, I don’t have any friends. And finally, I just don’t get it. Then again, I didn’t get “The Simpsons” when they first came out. D’oh!

Get Hipper

And I resolve to re-enter the pop culture world in general. My social and cultural life came to a screeching halt near midnight on Sept. 29, 2007: One moment I was innocently watching the Colorado Rockies battle into their first playoffs in 12 years, and the next I was blasted onto a four-year hyper-blur of crying, spoon-feeding, and diaper-changing—for the non-parent readers, I’m describing child-rearing, not residency training, which is admittedly often marked by these same mileposts. Now 4 and 2 years old, my kiddos have finally reached the stages of self-care that allow for my gradual re-entry into the outside world.

As such, I resolve to go to a movie (in the theater) again. The last two movies we saw in the theatre in 2007 were chosen by my pregnant wife and contained an uncomfortable subliminal theme—Knocked Up (pregnant woman hates impregnating sloth of a man), Juno (pregnant woman has love-hate relationship with pasty, impregnating nerd in tight gym shorts).

I’m also interested to see what’s on TV and on the radio. When I last turned off the cathodes, “Lost” was big; ditto “The Sopranos.” And in a clearly ill-fated second season, “Dancing with the Stars” was well on its way to its undeniable cancellation. Musically, Britney was shaving her head and Jordin Sparks was edging out Sanjaya’s faux-hawk on “Idol.”

I’m also looking forward to learning what a Kardashian is (a sweater?), explaining the strange pull toward vampire romances, and discovering the difference between a Pippa and a Snooki. Should be fun. I just hope I don’t catch “Bieber Fever.”

Aspire To “Be The Cup”

Finally, in 2012, I resolve to live up to the coffee cup—you know, the Father’s Day 2011 gift emblazoned with “World’s Best Dad.” I’m sure you all feel this in your own way—that constant tension between work and life. In 2011, work won a few too many of the tug-o’-wars. Too many missed gymnastics lessons, soccer practices, parent events at daycare, and late dinners. 2012 will be different.

I resolve to teach my son the art of hitting a curveball (even if it’s off a tee) and my daughter her letters and numbers. The dogs will get more tennis balls, the wife fewer resolutions to review.

In fact, this year is going to be totally different. This is the year my to-do list doesn’t once again end as an “undid list.” This is the year I will accomplish my resolutions … not just one or two, but all of my resolutions.

And I might just write a children’s book for good measure.

Dr. Glasheen is The Hospitalist’s physician editor.

Pornography. There can be few better hooks for readers than that. Just typing the word is a bit uncomfortable. As is, I imagine, reading it. But it’s effective, and likely why you’ve made it to word 37 of my column—34 words further than you usually get, I imagine.

“What about pornography?” you ask with bated breath. “What could pornography possibly have to do with hospital medicine?” your mind wonders. “Is this the column that (finally) gets Glasheen fired?” the ambulance chaser in you titillates.

By now, you’ve no doubt heard the famous Potter Stewart definition of pornography: “I know it when I see it.” That’s how the former U.S. Supreme Court justice described his threshold for recognizing pornography. It was made famous in a 1960s decision about whether a particular movie scene was protected by the 1st Amendment right to free speech or, indeed, a pornographic obscenity to be censured. Stewart, who clearly recognized the need to “define” pornography, also recognized the inherent challenges in doing so. The I-know-it-when-I-see-it benchmark is, of course, flawed, but I defy you to come up with a better definition.

Quality Is, of Course…

I was thinking about pornography (another discomforting phrase to type) recently—and Potter Stewart’s challenge in defining it, specifically—when I was asked about quality in healthcare. The query, which occurred during a several-hour, mind-numbing meeting (is there another type of several-hour meeting?), was “What is quality?” The question, laced with hostility and dripping with antagonism, was posed by a senior physician and directed pointedly at me. Indignantly, I cleared my throat, mentally stepping onto my pedestal to ceremoniously topple this academic egghead with my erudite response.

“Well, quality is, of course,” I confidently retorted, the “of course” added to demonstrate my moral superiority, “the ability to … uhhh, you see … ummmm, you know.” At which point I again cleared my throat not once, not twice, but a socially awkward three times before employing the timed-honored, full-body shock-twitch that signifies that you’ve just received an urgent vibrate page (faked, of course) and excused myself from the meeting, never to return.

The reality is that I struggle to define quality. Like Chief Justice Stewart, I think I know quality when I see it, but more precise definitions can be elusive.

And distracting.

It’s Not My Job

Just this morning, I read a news release from a respected physician group trumpeting the fact that their advocacy resulted in the federal government reducing the number of quality data-point requirements in their final rule for accountable-care organizations (ACOs) from 66 to 33. Trumpeting? Is this a good thing? Should we be supporting fewer quality measures? The article quoted a physician leader saying that the original reporting requirements were too burdensome. Too burdensome to whom? My guess is the recipients of our care, often referred to as our patients, wouldn’t categorize quality assurance as “too burdensome.”

I was at another meeting recently in which a respected colleague related her take on the physician role in improving quality. “I don’t think that’s a physician’s job. That’s what we have a quality department for,” she noted. “It’s just too expensive, time-consuming, and boring for physicians to do that kind of work.”

Too burdensome? Not a physician’s job to ensure the delivery of quality care? While I understand the sentiment (the need to have support staff collecting data, recognition of the huge infrastructure requirements, etc.), I can’t help but think that these types of responses are a large part of the struggle we are having with improving quality.

Then again, I would hazard that 0.0 percent of physicians would argue with the premise that we are obliged by the Hippocratic Oath, our moral compass, and our sense of professionalism to provide the best possible care to our patients. If we accept that we aren’t doing that—and we aren’t—then what is the disconnect? Why aren’t we seeking more quality data points? Why isn’t this “our job”?

Definitional Disconnect

Well, the truth is, it is our job. And we know it. The problem is that quality isn’t universally defined and the process of trying to define it often distracts us from the true task at hand—improving patient care.

Few of us would argue that a wrong-site surgery or anaphylaxis from administration of a medication known to have caused an allergy represents a suboptimal level of care. But more often than not, we see quality being measured and defined in less concrete, more obscure ways—ways that my eyes may not view as low-quality. These definitions are inherently flawed and breed contempt among providers who are told they aren’t passing muster in metrics they don’t see as “quality.”

So the real disconnect is definitional. Is quality defined by the Institute of Medicine characteristics of safe, effective, patient-centered, timely, efficient, and equitable care? Or is it the rates of underuse, overuse, and misuse of medical treatments and procedures? Or is it defined by individual quality metrics such as those captured by the Centers for Medicare & Medicaid Services (CMS)—you know, things like hospital fall rates, perioperative antibiotic usage, beta-blockers after MI, or whether a patient reported their bathroom as being clean?

Is 30% of the quality of care that we deliver referable to the patient experience (as measured by HCAHPS), as the new value-based purchasing program would have us believe? Is it hospital accreditation through the Joint Commission? Or physician certification through our parent boards? Is quality measured by a physician’s cognitive or technical skills, or where they went to school? Is it experience, medical knowledge, guideline usage?

We use such a mystifying array of metrics to define quality that it confuses the issue such that physicians who personally believe they are doing a good job can become disenfranchised. To a physician who provides clinically appropriate care around a surgical procedure or treatment of pneumonia, it can be demeaning and demoralizing to suggest that his or her patient did not receive “high quality” care because the bathroom wasn’t clean or the patient didn’t get a flu shot. Yet, this is the message we often send—a message that alienates many physicians, making them cynical about quality and disengaged in quality improvement. The result is that they seek fewer quality data points and defer the job of improving quality to someone else.

Make no mistake: Quality measures have an important role in our healthcare landscape. But to the degree that defining quality confuses, alienates, or disenfranchises providers, we should stop trying to define it. Quality is not a thing, a metric, or an outcome. It is not an elusive, unquantifiable creature that is achievable only by the elite. Quality is simply providing the best possible care. And quality improvement is simply closing the gap between the best possible care and actual care.

In this regard, we can learn a lot from Potter Stewart. We know quality when we see it. And we know what an absence of quality looks like.

Let’s close that gap by putting less energy into defining quality, and putting more energy into the tenacious pursuit of quality.

Dr. Glasheen is physician editor of The Hospitalist.

Pornography. There can be few better hooks for readers than that. Just typing the word is a bit uncomfortable. As is, I imagine, reading it. But it’s effective, and likely why you’ve made it to word 37 of my column—34 words further than you usually get, I imagine.

“What about pornography?” you ask with bated breath. “What could pornography possibly have to do with hospital medicine?” your mind wonders. “Is this the column that (finally) gets Glasheen fired?” the ambulance chaser in you titillates.

By now, you’ve no doubt heard the famous Potter Stewart definition of pornography: “I know it when I see it.” That’s how the former U.S. Supreme Court justice described his threshold for recognizing pornography. It was made famous in a 1960s decision about whether a particular movie scene was protected by the 1st Amendment right to free speech or, indeed, a pornographic obscenity to be censured. Stewart, who clearly recognized the need to “define” pornography, also recognized the inherent challenges in doing so. The I-know-it-when-I-see-it benchmark is, of course, flawed, but I defy you to come up with a better definition.

Quality Is, of Course…

I was thinking about pornography (another discomforting phrase to type) recently—and Potter Stewart’s challenge in defining it, specifically—when I was asked about quality in healthcare. The query, which occurred during a several-hour, mind-numbing meeting (is there another type of several-hour meeting?), was “What is quality?” The question, laced with hostility and dripping with antagonism, was posed by a senior physician and directed pointedly at me. Indignantly, I cleared my throat, mentally stepping onto my pedestal to ceremoniously topple this academic egghead with my erudite response.

“Well, quality is, of course,” I confidently retorted, the “of course” added to demonstrate my moral superiority, “the ability to … uhhh, you see … ummmm, you know.” At which point I again cleared my throat not once, not twice, but a socially awkward three times before employing the timed-honored, full-body shock-twitch that signifies that you’ve just received an urgent vibrate page (faked, of course) and excused myself from the meeting, never to return.

The reality is that I struggle to define quality. Like Chief Justice Stewart, I think I know quality when I see it, but more precise definitions can be elusive.

And distracting.

It’s Not My Job

Just this morning, I read a news release from a respected physician group trumpeting the fact that their advocacy resulted in the federal government reducing the number of quality data-point requirements in their final rule for accountable-care organizations (ACOs) from 66 to 33. Trumpeting? Is this a good thing? Should we be supporting fewer quality measures? The article quoted a physician leader saying that the original reporting requirements were too burdensome. Too burdensome to whom? My guess is the recipients of our care, often referred to as our patients, wouldn’t categorize quality assurance as “too burdensome.”

I was at another meeting recently in which a respected colleague related her take on the physician role in improving quality. “I don’t think that’s a physician’s job. That’s what we have a quality department for,” she noted. “It’s just too expensive, time-consuming, and boring for physicians to do that kind of work.”

Too burdensome? Not a physician’s job to ensure the delivery of quality care? While I understand the sentiment (the need to have support staff collecting data, recognition of the huge infrastructure requirements, etc.), I can’t help but think that these types of responses are a large part of the struggle we are having with improving quality.

Then again, I would hazard that 0.0 percent of physicians would argue with the premise that we are obliged by the Hippocratic Oath, our moral compass, and our sense of professionalism to provide the best possible care to our patients. If we accept that we aren’t doing that—and we aren’t—then what is the disconnect? Why aren’t we seeking more quality data points? Why isn’t this “our job”?

Definitional Disconnect

Well, the truth is, it is our job. And we know it. The problem is that quality isn’t universally defined and the process of trying to define it often distracts us from the true task at hand—improving patient care.

Few of us would argue that a wrong-site surgery or anaphylaxis from administration of a medication known to have caused an allergy represents a suboptimal level of care. But more often than not, we see quality being measured and defined in less concrete, more obscure ways—ways that my eyes may not view as low-quality. These definitions are inherently flawed and breed contempt among providers who are told they aren’t passing muster in metrics they don’t see as “quality.”

So the real disconnect is definitional. Is quality defined by the Institute of Medicine characteristics of safe, effective, patient-centered, timely, efficient, and equitable care? Or is it the rates of underuse, overuse, and misuse of medical treatments and procedures? Or is it defined by individual quality metrics such as those captured by the Centers for Medicare & Medicaid Services (CMS)—you know, things like hospital fall rates, perioperative antibiotic usage, beta-blockers after MI, or whether a patient reported their bathroom as being clean?

Is 30% of the quality of care that we deliver referable to the patient experience (as measured by HCAHPS), as the new value-based purchasing program would have us believe? Is it hospital accreditation through the Joint Commission? Or physician certification through our parent boards? Is quality measured by a physician’s cognitive or technical skills, or where they went to school? Is it experience, medical knowledge, guideline usage?

We use such a mystifying array of metrics to define quality that it confuses the issue such that physicians who personally believe they are doing a good job can become disenfranchised. To a physician who provides clinically appropriate care around a surgical procedure or treatment of pneumonia, it can be demeaning and demoralizing to suggest that his or her patient did not receive “high quality” care because the bathroom wasn’t clean or the patient didn’t get a flu shot. Yet, this is the message we often send—a message that alienates many physicians, making them cynical about quality and disengaged in quality improvement. The result is that they seek fewer quality data points and defer the job of improving quality to someone else.

Make no mistake: Quality measures have an important role in our healthcare landscape. But to the degree that defining quality confuses, alienates, or disenfranchises providers, we should stop trying to define it. Quality is not a thing, a metric, or an outcome. It is not an elusive, unquantifiable creature that is achievable only by the elite. Quality is simply providing the best possible care. And quality improvement is simply closing the gap between the best possible care and actual care.

In this regard, we can learn a lot from Potter Stewart. We know quality when we see it. And we know what an absence of quality looks like.

Let’s close that gap by putting less energy into defining quality, and putting more energy into the tenacious pursuit of quality.

Dr. Glasheen is physician editor of The Hospitalist.

Pornography. There can be few better hooks for readers than that. Just typing the word is a bit uncomfortable. As is, I imagine, reading it. But it’s effective, and likely why you’ve made it to word 37 of my column—34 words further than you usually get, I imagine.

“What about pornography?” you ask with bated breath. “What could pornography possibly have to do with hospital medicine?” your mind wonders. “Is this the column that (finally) gets Glasheen fired?” the ambulance chaser in you titillates.

By now, you’ve no doubt heard the famous Potter Stewart definition of pornography: “I know it when I see it.” That’s how the former U.S. Supreme Court justice described his threshold for recognizing pornography. It was made famous in a 1960s decision about whether a particular movie scene was protected by the 1st Amendment right to free speech or, indeed, a pornographic obscenity to be censured. Stewart, who clearly recognized the need to “define” pornography, also recognized the inherent challenges in doing so. The I-know-it-when-I-see-it benchmark is, of course, flawed, but I defy you to come up with a better definition.

Quality Is, of Course…

I was thinking about pornography (another discomforting phrase to type) recently—and Potter Stewart’s challenge in defining it, specifically—when I was asked about quality in healthcare. The query, which occurred during a several-hour, mind-numbing meeting (is there another type of several-hour meeting?), was “What is quality?” The question, laced with hostility and dripping with antagonism, was posed by a senior physician and directed pointedly at me. Indignantly, I cleared my throat, mentally stepping onto my pedestal to ceremoniously topple this academic egghead with my erudite response.

“Well, quality is, of course,” I confidently retorted, the “of course” added to demonstrate my moral superiority, “the ability to … uhhh, you see … ummmm, you know.” At which point I again cleared my throat not once, not twice, but a socially awkward three times before employing the timed-honored, full-body shock-twitch that signifies that you’ve just received an urgent vibrate page (faked, of course) and excused myself from the meeting, never to return.

The reality is that I struggle to define quality. Like Chief Justice Stewart, I think I know quality when I see it, but more precise definitions can be elusive.

And distracting.

It’s Not My Job

Just this morning, I read a news release from a respected physician group trumpeting the fact that their advocacy resulted in the federal government reducing the number of quality data-point requirements in their final rule for accountable-care organizations (ACOs) from 66 to 33. Trumpeting? Is this a good thing? Should we be supporting fewer quality measures? The article quoted a physician leader saying that the original reporting requirements were too burdensome. Too burdensome to whom? My guess is the recipients of our care, often referred to as our patients, wouldn’t categorize quality assurance as “too burdensome.”

I was at another meeting recently in which a respected colleague related her take on the physician role in improving quality. “I don’t think that’s a physician’s job. That’s what we have a quality department for,” she noted. “It’s just too expensive, time-consuming, and boring for physicians to do that kind of work.”

Too burdensome? Not a physician’s job to ensure the delivery of quality care? While I understand the sentiment (the need to have support staff collecting data, recognition of the huge infrastructure requirements, etc.), I can’t help but think that these types of responses are a large part of the struggle we are having with improving quality.

Then again, I would hazard that 0.0 percent of physicians would argue with the premise that we are obliged by the Hippocratic Oath, our moral compass, and our sense of professionalism to provide the best possible care to our patients. If we accept that we aren’t doing that—and we aren’t—then what is the disconnect? Why aren’t we seeking more quality data points? Why isn’t this “our job”?

Definitional Disconnect

Well, the truth is, it is our job. And we know it. The problem is that quality isn’t universally defined and the process of trying to define it often distracts us from the true task at hand—improving patient care.

Few of us would argue that a wrong-site surgery or anaphylaxis from administration of a medication known to have caused an allergy represents a suboptimal level of care. But more often than not, we see quality being measured and defined in less concrete, more obscure ways—ways that my eyes may not view as low-quality. These definitions are inherently flawed and breed contempt among providers who are told they aren’t passing muster in metrics they don’t see as “quality.”

So the real disconnect is definitional. Is quality defined by the Institute of Medicine characteristics of safe, effective, patient-centered, timely, efficient, and equitable care? Or is it the rates of underuse, overuse, and misuse of medical treatments and procedures? Or is it defined by individual quality metrics such as those captured by the Centers for Medicare & Medicaid Services (CMS)—you know, things like hospital fall rates, perioperative antibiotic usage, beta-blockers after MI, or whether a patient reported their bathroom as being clean?

Is 30% of the quality of care that we deliver referable to the patient experience (as measured by HCAHPS), as the new value-based purchasing program would have us believe? Is it hospital accreditation through the Joint Commission? Or physician certification through our parent boards? Is quality measured by a physician’s cognitive or technical skills, or where they went to school? Is it experience, medical knowledge, guideline usage?

We use such a mystifying array of metrics to define quality that it confuses the issue such that physicians who personally believe they are doing a good job can become disenfranchised. To a physician who provides clinically appropriate care around a surgical procedure or treatment of pneumonia, it can be demeaning and demoralizing to suggest that his or her patient did not receive “high quality” care because the bathroom wasn’t clean or the patient didn’t get a flu shot. Yet, this is the message we often send—a message that alienates many physicians, making them cynical about quality and disengaged in quality improvement. The result is that they seek fewer quality data points and defer the job of improving quality to someone else.

Make no mistake: Quality measures have an important role in our healthcare landscape. But to the degree that defining quality confuses, alienates, or disenfranchises providers, we should stop trying to define it. Quality is not a thing, a metric, or an outcome. It is not an elusive, unquantifiable creature that is achievable only by the elite. Quality is simply providing the best possible care. And quality improvement is simply closing the gap between the best possible care and actual care.

In this regard, we can learn a lot from Potter Stewart. We know quality when we see it. And we know what an absence of quality looks like.

Let’s close that gap by putting less energy into defining quality, and putting more energy into the tenacious pursuit of quality.

Dr. Glasheen is physician editor of The Hospitalist.

If today’s learners interact with grumpy, overworked, unsatisfied, marginalized intern-extenders, they will quickly up-regulate the gastroenterology gene, and the best and brightest will start to flow out of our pipeline.

Are hospitalists happy? Are we satisfied, stressed, burned out? How is this impacting our field? What can we do about it? The Hospitalist this month takes a hard look at the often overlooked issue of career satisfaction and its cousins burnout, stress, and turnover.

After a decade of taking a fly-by-the-seat-of-our-pants approach to building, managing, and remediating HM programs, we finally have some concrete data to help guide us in building our programs. In fact, no fewer than three research papers studying these issues have been published recently—two of them from my institution.^1,2,3 As such, I’ve been thinking about this a lot and what this means to the field in general and, more specifically, academic hospitalists.

Now I recognize that academic hospitalists make up but a fraction of the hospitalist work force; nonetheless, I believe it is an important fraction, even for community hospitalists. As I’ve written before, HM’s pipeline is dependent upon future hospitalists (commonly referred to as residents and students) engaging with fulfilled, satisfied, and successful academic hospitalists—the kind of specialists that look and feel like other specialists. If today’s learners interact with grumpy, overworked, unsatisfied, marginalized intern-extenders, they will quickly up-regulate the gastroenterology gene, and the best and brightest will start to flow out of our pipeline.

So what do these studies show? How do we assimilate these data into our programs, and how can we use it to produce more sustainable, effective, and productive academic HM groups? Here’s my take: a seven-step prescription of sorts for what ails academic HM.

Step 1: Honor Thy Mission

I was having dinner recently with a higher-level executive with a national hospitalist management company that primarily staffs community hospitals. An uncomfortable pause, followed by gasping sounds, ensued after I told him our starting academic salary. After collecting himself, he asked how on Earth I could recruit hospitalists at such a low salary—I think hoping to discover the fount to lower personnel costs. Simply put, some people are willing to sacrifice salary for the academic mission and all its trappings.

In fact, the only differential advantage academic programs have over their community brethren is the ability to be, well, academic—that is, to teach, develop, innovate, disseminate, and create the knowledge base that fuels our specialty. The academic mission is not for everyone. But there is a pool of individuals who are willing to forego financial compensation for compensation of a different sort. Take away the academic mission, and the two jobs start to look similar, salaries equilibrate, and people with academic leanings become unsatisfied.

And burned out. I’d argue that career-fit mismatch is a main cause of academic hospitalist burnout—I come to academics to be academic but find in turn a community job in a teaching hospital. This is supported by data showing that 75% of academic hospitalists described their primary role as either teacher or investigator, yet most (52%) spent 40% or less of their time with learners, and 57% had 20% or less of their time protected for scholarly pursuits.1 This epitomizes career-fit mismatch, and likely explains why nearly a quarter of academic hospitalists are burned out.

Step 2: Man Cannot Live by wRVUs Alone

An extension of this idea is that academicians need time for scholarship. In fact, academic productivity cannot be measured in wRVUs alone. Don’t get me wrong; hospitalists need to support their salaries and see lots of patients. But teaching the next generation, developing and disseminating knowledge, and generating a promotable academic portfolio takes time—time that can’t be shoe-horned into 200-plus busy clinical shifts a year. This is supported by evidence showing that more than 20% of protected non-clinical time was one of the biggest predictors of academic productivity.²

Five thousand wRVUs? Way too much. Four thousand? Getting warmer. Three thousand? Try a little lower. I’d go out on a limb and say the right number is slightly below 3,000 wRVUs.

I suspect this will raise some eyebrows among hospital administrators who fund these programs—and I welcome the letters. But before you pick up your pen, consider this: What is the value of educating our future physicians (something most teaching hospitals are funded to do through graduate medical education dollars), discovery, scholarship, hospital quality improvement (QI), and sustainable faculty careers? Academic hospitalists have decided to value it with a pay cut. Are our administrators willing to make a similar sacrifice?

Step 3: Culture of Scholarship

Protected time comes with a responsibility to produce. Discovering, publishing, speaking, and presenting are hard work—so hard that the default of not doing it presents an all-too-often-enticing option. This in part explains why most academic hospitalists have not published a first-author, peer-reviewed paper (51% have not), given institutional medical grand rounds (74%), or presented at a national meeting (75%).¹

This is where cultivating a group culture of scholarship replete with expectations (# of publications/year), opportunities to present work (hospitalist Grand Rounds), faculty development, mentorship and institutional support (financial commitment and time to teach) are paramount.

Step 4: Academic Currency

Let me emphasize that last point. The majority of academic hospitalists lack formal fellowship training and, therefore, are not going to be funded or promoted based on research outputs. In fact, more than 90% of hospitalists will be promoted (or not) through the clinician-educator pathway. That means our academic currency is teaching and curriculum development.

That’s why the majority of academic hospitalists spending the majority of their time on non-teaching services is a major problem. It’s akin to an eternally unfunded researcher trying to get promoted as a clinician-investigator. It’s not going to happen.

Duty-hour restrictions, growing hospital services, PCP exodus from our hospitals, and the growth of comanagement are driving further hospitalist expansion in teaching hospitals. This means more mouths competing for a shrinking teaching pie. I don’t have the solution, but I suspect that those clinician-educators spending less than 25% of their time with learners will find it difficult to be sated, successful, and promotable in academia.

Step 5: Mentorship

Mentorship unquestionably is tied to publications, presentations, grant funding, job satisfaction, and, ultimately, academic promotion. Yet only 42% of academic hospitalists report having a mentor.² Of those with a mentor, the vast majority spend less than four hours a year with their mentor.² I can identify no more obvious and urgent problem to solve in academic HM.

Step 6: Job Structure

The single most powerful predictors of burnout and low satisfaction are a lack of work/life balance, autonomy, and control over one’s work environment. In fact, control over work schedule (odds ratio 5.35) and amount of personal time (OR 2.51) were the biggest predictors of burnout for academic hospitalists. Similarly, control over work schedule (OR 4.82) and amount of personal time (OR 2.37) predicted low satisfaction.¹ The bottom line is that flexibility, autonomy, and control are essential components to academic fulfillment.

Step 7: The Secret Sauce

There you have it—a prescription for success.

Well, it turns out we are still missing one thing—one final ingredient, something mysterious and all-too-often lacking. A magic potion that allows for the right people to be in the right places with the right tools to succeed. With it, our potential knows no bounds. Without it, we’ll continue to struggle. In fact, its absence is one of the single biggest predictors of low satisfaction for academic hospitalists.¹

What is “it”?

Leadership.

HM needs individuals to fill this prescription. The problem is that our leaders are often young, inexperienced, and raw. They are tasked with creating positions with an academic focus, reasonable clinical productivity expectations, a culture that promotes scholarship, sufficient non-clinical time, adequate time with learners, robust mentorship, and ample autonomy, work-life balance, and a chance to grow. To do this, they need direction, mentorship, a peer network, and skills development.

At least that’s what I need.

In fact, come to think of it, I think there is an eighth step for academic success—the need to develop an external academic peer network, to grow together, to actively engage, and depend on for help. As such, I hope you’ll partake in step No. 8 with me—at HM12, Academic Hospitalist Academy, Leadership Academies, and the Academic Summit. I hope to see you soon.

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. He is physician editor of The Hospitalist and course director of the SHM’s 2012 annual meeting (www.hospitalmedicine2012.org).

References

1. Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med. 2011;171:782-785.
2. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. Epub online: Sept. 28, 2011.
3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck T. Worklife and satisfaction of hospitalists: Toward flourishing careers. J Gen Intern Med. Epub online: July 20, 2011.

If today’s learners interact with grumpy, overworked, unsatisfied, marginalized intern-extenders, they will quickly up-regulate the gastroenterology gene, and the best and brightest will start to flow out of our pipeline.

Are hospitalists happy? Are we satisfied, stressed, burned out? How is this impacting our field? What can we do about it? The Hospitalist this month takes a hard look at the often overlooked issue of career satisfaction and its cousins burnout, stress, and turnover.

After a decade of taking a fly-by-the-seat-of-our-pants approach to building, managing, and remediating HM programs, we finally have some concrete data to help guide us in building our programs. In fact, no fewer than three research papers studying these issues have been published recently—two of them from my institution.^1,2,3 As such, I’ve been thinking about this a lot and what this means to the field in general and, more specifically, academic hospitalists.

Now I recognize that academic hospitalists make up but a fraction of the hospitalist work force; nonetheless, I believe it is an important fraction, even for community hospitalists. As I’ve written before, HM’s pipeline is dependent upon future hospitalists (commonly referred to as residents and students) engaging with fulfilled, satisfied, and successful academic hospitalists—the kind of specialists that look and feel like other specialists. If today’s learners interact with grumpy, overworked, unsatisfied, marginalized intern-extenders, they will quickly up-regulate the gastroenterology gene, and the best and brightest will start to flow out of our pipeline.

So what do these studies show? How do we assimilate these data into our programs, and how can we use it to produce more sustainable, effective, and productive academic HM groups? Here’s my take: a seven-step prescription of sorts for what ails academic HM.

Step 1: Honor Thy Mission

I was having dinner recently with a higher-level executive with a national hospitalist management company that primarily staffs community hospitals. An uncomfortable pause, followed by gasping sounds, ensued after I told him our starting academic salary. After collecting himself, he asked how on Earth I could recruit hospitalists at such a low salary—I think hoping to discover the fount to lower personnel costs. Simply put, some people are willing to sacrifice salary for the academic mission and all its trappings.

In fact, the only differential advantage academic programs have over their community brethren is the ability to be, well, academic—that is, to teach, develop, innovate, disseminate, and create the knowledge base that fuels our specialty. The academic mission is not for everyone. But there is a pool of individuals who are willing to forego financial compensation for compensation of a different sort. Take away the academic mission, and the two jobs start to look similar, salaries equilibrate, and people with academic leanings become unsatisfied.

And burned out. I’d argue that career-fit mismatch is a main cause of academic hospitalist burnout—I come to academics to be academic but find in turn a community job in a teaching hospital. This is supported by data showing that 75% of academic hospitalists described their primary role as either teacher or investigator, yet most (52%) spent 40% or less of their time with learners, and 57% had 20% or less of their time protected for scholarly pursuits.1 This epitomizes career-fit mismatch, and likely explains why nearly a quarter of academic hospitalists are burned out.

Step 2: Man Cannot Live by wRVUs Alone

An extension of this idea is that academicians need time for scholarship. In fact, academic productivity cannot be measured in wRVUs alone. Don’t get me wrong; hospitalists need to support their salaries and see lots of patients. But teaching the next generation, developing and disseminating knowledge, and generating a promotable academic portfolio takes time—time that can’t be shoe-horned into 200-plus busy clinical shifts a year. This is supported by evidence showing that more than 20% of protected non-clinical time was one of the biggest predictors of academic productivity.²

Five thousand wRVUs? Way too much. Four thousand? Getting warmer. Three thousand? Try a little lower. I’d go out on a limb and say the right number is slightly below 3,000 wRVUs.

I suspect this will raise some eyebrows among hospital administrators who fund these programs—and I welcome the letters. But before you pick up your pen, consider this: What is the value of educating our future physicians (something most teaching hospitals are funded to do through graduate medical education dollars), discovery, scholarship, hospital quality improvement (QI), and sustainable faculty careers? Academic hospitalists have decided to value it with a pay cut. Are our administrators willing to make a similar sacrifice?

Step 3: Culture of Scholarship

Protected time comes with a responsibility to produce. Discovering, publishing, speaking, and presenting are hard work—so hard that the default of not doing it presents an all-too-often-enticing option. This in part explains why most academic hospitalists have not published a first-author, peer-reviewed paper (51% have not), given institutional medical grand rounds (74%), or presented at a national meeting (75%).¹

This is where cultivating a group culture of scholarship replete with expectations (# of publications/year), opportunities to present work (hospitalist Grand Rounds), faculty development, mentorship and institutional support (financial commitment and time to teach) are paramount.

Step 4: Academic Currency

Let me emphasize that last point. The majority of academic hospitalists lack formal fellowship training and, therefore, are not going to be funded or promoted based on research outputs. In fact, more than 90% of hospitalists will be promoted (or not) through the clinician-educator pathway. That means our academic currency is teaching and curriculum development.

That’s why the majority of academic hospitalists spending the majority of their time on non-teaching services is a major problem. It’s akin to an eternally unfunded researcher trying to get promoted as a clinician-investigator. It’s not going to happen.

Duty-hour restrictions, growing hospital services, PCP exodus from our hospitals, and the growth of comanagement are driving further hospitalist expansion in teaching hospitals. This means more mouths competing for a shrinking teaching pie. I don’t have the solution, but I suspect that those clinician-educators spending less than 25% of their time with learners will find it difficult to be sated, successful, and promotable in academia.

Step 5: Mentorship

Mentorship unquestionably is tied to publications, presentations, grant funding, job satisfaction, and, ultimately, academic promotion. Yet only 42% of academic hospitalists report having a mentor.² Of those with a mentor, the vast majority spend less than four hours a year with their mentor.² I can identify no more obvious and urgent problem to solve in academic HM.

Step 6: Job Structure

The single most powerful predictors of burnout and low satisfaction are a lack of work/life balance, autonomy, and control over one’s work environment. In fact, control over work schedule (odds ratio 5.35) and amount of personal time (OR 2.51) were the biggest predictors of burnout for academic hospitalists. Similarly, control over work schedule (OR 4.82) and amount of personal time (OR 2.37) predicted low satisfaction.¹ The bottom line is that flexibility, autonomy, and control are essential components to academic fulfillment.

Step 7: The Secret Sauce

There you have it—a prescription for success.

Well, it turns out we are still missing one thing—one final ingredient, something mysterious and all-too-often lacking. A magic potion that allows for the right people to be in the right places with the right tools to succeed. With it, our potential knows no bounds. Without it, we’ll continue to struggle. In fact, its absence is one of the single biggest predictors of low satisfaction for academic hospitalists.¹

What is “it”?

Leadership.

HM needs individuals to fill this prescription. The problem is that our leaders are often young, inexperienced, and raw. They are tasked with creating positions with an academic focus, reasonable clinical productivity expectations, a culture that promotes scholarship, sufficient non-clinical time, adequate time with learners, robust mentorship, and ample autonomy, work-life balance, and a chance to grow. To do this, they need direction, mentorship, a peer network, and skills development.

At least that’s what I need.

In fact, come to think of it, I think there is an eighth step for academic success—the need to develop an external academic peer network, to grow together, to actively engage, and depend on for help. As such, I hope you’ll partake in step No. 8 with me—at HM12, Academic Hospitalist Academy, Leadership Academies, and the Academic Summit. I hope to see you soon.

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. He is physician editor of The Hospitalist and course director of the SHM’s 2012 annual meeting (www.hospitalmedicine2012.org).

References

1. Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med. 2011;171:782-785.
2. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. Epub online: Sept. 28, 2011.
3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck T. Worklife and satisfaction of hospitalists: Toward flourishing careers. J Gen Intern Med. Epub online: July 20, 2011.

If today’s learners interact with grumpy, overworked, unsatisfied, marginalized intern-extenders, they will quickly up-regulate the gastroenterology gene, and the best and brightest will start to flow out of our pipeline.

Are hospitalists happy? Are we satisfied, stressed, burned out? How is this impacting our field? What can we do about it? The Hospitalist this month takes a hard look at the often overlooked issue of career satisfaction and its cousins burnout, stress, and turnover.

After a decade of taking a fly-by-the-seat-of-our-pants approach to building, managing, and remediating HM programs, we finally have some concrete data to help guide us in building our programs. In fact, no fewer than three research papers studying these issues have been published recently—two of them from my institution.^1,2,3 As such, I’ve been thinking about this a lot and what this means to the field in general and, more specifically, academic hospitalists.

Now I recognize that academic hospitalists make up but a fraction of the hospitalist work force; nonetheless, I believe it is an important fraction, even for community hospitalists. As I’ve written before, HM’s pipeline is dependent upon future hospitalists (commonly referred to as residents and students) engaging with fulfilled, satisfied, and successful academic hospitalists—the kind of specialists that look and feel like other specialists. If today’s learners interact with grumpy, overworked, unsatisfied, marginalized intern-extenders, they will quickly up-regulate the gastroenterology gene, and the best and brightest will start to flow out of our pipeline.

So what do these studies show? How do we assimilate these data into our programs, and how can we use it to produce more sustainable, effective, and productive academic HM groups? Here’s my take: a seven-step prescription of sorts for what ails academic HM.

Step 1: Honor Thy Mission

I was having dinner recently with a higher-level executive with a national hospitalist management company that primarily staffs community hospitals. An uncomfortable pause, followed by gasping sounds, ensued after I told him our starting academic salary. After collecting himself, he asked how on Earth I could recruit hospitalists at such a low salary—I think hoping to discover the fount to lower personnel costs. Simply put, some people are willing to sacrifice salary for the academic mission and all its trappings.

In fact, the only differential advantage academic programs have over their community brethren is the ability to be, well, academic—that is, to teach, develop, innovate, disseminate, and create the knowledge base that fuels our specialty. The academic mission is not for everyone. But there is a pool of individuals who are willing to forego financial compensation for compensation of a different sort. Take away the academic mission, and the two jobs start to look similar, salaries equilibrate, and people with academic leanings become unsatisfied.

And burned out. I’d argue that career-fit mismatch is a main cause of academic hospitalist burnout—I come to academics to be academic but find in turn a community job in a teaching hospital. This is supported by data showing that 75% of academic hospitalists described their primary role as either teacher or investigator, yet most (52%) spent 40% or less of their time with learners, and 57% had 20% or less of their time protected for scholarly pursuits.1 This epitomizes career-fit mismatch, and likely explains why nearly a quarter of academic hospitalists are burned out.

Step 2: Man Cannot Live by wRVUs Alone

An extension of this idea is that academicians need time for scholarship. In fact, academic productivity cannot be measured in wRVUs alone. Don’t get me wrong; hospitalists need to support their salaries and see lots of patients. But teaching the next generation, developing and disseminating knowledge, and generating a promotable academic portfolio takes time—time that can’t be shoe-horned into 200-plus busy clinical shifts a year. This is supported by evidence showing that more than 20% of protected non-clinical time was one of the biggest predictors of academic productivity.²

Five thousand wRVUs? Way too much. Four thousand? Getting warmer. Three thousand? Try a little lower. I’d go out on a limb and say the right number is slightly below 3,000 wRVUs.

I suspect this will raise some eyebrows among hospital administrators who fund these programs—and I welcome the letters. But before you pick up your pen, consider this: What is the value of educating our future physicians (something most teaching hospitals are funded to do through graduate medical education dollars), discovery, scholarship, hospital quality improvement (QI), and sustainable faculty careers? Academic hospitalists have decided to value it with a pay cut. Are our administrators willing to make a similar sacrifice?

Step 3: Culture of Scholarship

Protected time comes with a responsibility to produce. Discovering, publishing, speaking, and presenting are hard work—so hard that the default of not doing it presents an all-too-often-enticing option. This in part explains why most academic hospitalists have not published a first-author, peer-reviewed paper (51% have not), given institutional medical grand rounds (74%), or presented at a national meeting (75%).¹

This is where cultivating a group culture of scholarship replete with expectations (# of publications/year), opportunities to present work (hospitalist Grand Rounds), faculty development, mentorship and institutional support (financial commitment and time to teach) are paramount.

Step 4: Academic Currency

Let me emphasize that last point. The majority of academic hospitalists lack formal fellowship training and, therefore, are not going to be funded or promoted based on research outputs. In fact, more than 90% of hospitalists will be promoted (or not) through the clinician-educator pathway. That means our academic currency is teaching and curriculum development.

That’s why the majority of academic hospitalists spending the majority of their time on non-teaching services is a major problem. It’s akin to an eternally unfunded researcher trying to get promoted as a clinician-investigator. It’s not going to happen.

Duty-hour restrictions, growing hospital services, PCP exodus from our hospitals, and the growth of comanagement are driving further hospitalist expansion in teaching hospitals. This means more mouths competing for a shrinking teaching pie. I don’t have the solution, but I suspect that those clinician-educators spending less than 25% of their time with learners will find it difficult to be sated, successful, and promotable in academia.

Step 5: Mentorship

Mentorship unquestionably is tied to publications, presentations, grant funding, job satisfaction, and, ultimately, academic promotion. Yet only 42% of academic hospitalists report having a mentor.² Of those with a mentor, the vast majority spend less than four hours a year with their mentor.² I can identify no more obvious and urgent problem to solve in academic HM.

Step 6: Job Structure

The single most powerful predictors of burnout and low satisfaction are a lack of work/life balance, autonomy, and control over one’s work environment. In fact, control over work schedule (odds ratio 5.35) and amount of personal time (OR 2.51) were the biggest predictors of burnout for academic hospitalists. Similarly, control over work schedule (OR 4.82) and amount of personal time (OR 2.37) predicted low satisfaction.¹ The bottom line is that flexibility, autonomy, and control are essential components to academic fulfillment.

Step 7: The Secret Sauce

There you have it—a prescription for success.

Well, it turns out we are still missing one thing—one final ingredient, something mysterious and all-too-often lacking. A magic potion that allows for the right people to be in the right places with the right tools to succeed. With it, our potential knows no bounds. Without it, we’ll continue to struggle. In fact, its absence is one of the single biggest predictors of low satisfaction for academic hospitalists.¹

What is “it”?

Leadership.

HM needs individuals to fill this prescription. The problem is that our leaders are often young, inexperienced, and raw. They are tasked with creating positions with an academic focus, reasonable clinical productivity expectations, a culture that promotes scholarship, sufficient non-clinical time, adequate time with learners, robust mentorship, and ample autonomy, work-life balance, and a chance to grow. To do this, they need direction, mentorship, a peer network, and skills development.

At least that’s what I need.

In fact, come to think of it, I think there is an eighth step for academic success—the need to develop an external academic peer network, to grow together, to actively engage, and depend on for help. As such, I hope you’ll partake in step No. 8 with me—at HM12, Academic Hospitalist Academy, Leadership Academies, and the Academic Summit. I hope to see you soon.

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. He is physician editor of The Hospitalist and course director of the SHM’s 2012 annual meeting (www.hospitalmedicine2012.org).

References

1. Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med. 2011;171:782-785.
2. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. Epub online: Sept. 28, 2011.
3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck T. Worklife and satisfaction of hospitalists: Toward flourishing careers. J Gen Intern Med. Epub online: July 20, 2011.

It was when my lung fell out that it hit me. No, come to think of it, it was before that, when a scorpion struck my left calf. Or it might have been when my heart exploded. No, it was earlier than that—probably around the time my right lower abdominal quadrant was gutted by that wild boar. No, actually, it was even earlier than that. Somewhere around the time I pulled my 204th muscle. Yeah, that was it. That’s when I first wondered why there is no “fun run” for safety.

Truth be told, there was no de-lunging, scorpions, cardiac explosion, or wild-boar-goring. It just felt like that. The reason: I was running. The occasion: an annual fun (?) run to support Crohn’s disease and ulcerative colitis. Why I, an out-of-shape specimen blessed with a superhero-like affinity for both chips and the couch, should be pounding the pavement early on a Saturday morning is a case study in wifely nagging.

And misplaced healthcare priorities.

You see, I have neither Crohn’s nor ulcerative colitis, have no friends or family members with them, and, frankly, rarely even provide care for patients with these diseases. What I do have is a gastroenterologist for a wife. A gastroenterologist who passionately supports gastroenterological problems; a gastroenterologist who doesn’t herself like to participate in fun runs; a gastroenterologist who relishes, apparently, seeing her husband sweat lactate while testing the anaerobic limits of the human organism. This was the nagging part.

As the gun reported at 7:30 a.m., there I was, fidgeting nervously at the starting line in a moth-eaten cotton tee from the last road race I had run—in 1989—while those around me gave my too-short, reversible, blue-and-white gym shorts the up-and-down. Cotton socks crotched, feet pre-blistered, I departed, feeling good—for the first four meters.

The next 4.99 kilometers proved slightly more daunting—providing an abundance of K’s to ponder the misplaced healthcare priorities part.

Running in The Trees

After I expertly buried the first 100-meter downhill, the race entered a well-worn, tree-lined footpath. I was shocked by both the splendor of the environs as well as the hordes of people passing me. I was comfortable with the concept of the taut young adults leaving me in their dust and, even, sort of, the superiorly fit elders. The pre-teens were more unsettling. As were the walkers—especially the walker using a walker.

It’s interesting, the relationship between road races and medical diseases. It’s not surprising, really, that generally healthy specimens would band together and use exercise as a weapon against disease—it’s actually quite noble. And common. My guess is your hometown counts numerous foot, bike, and foot-and-bike races supporting the eradication of myriad medical maladies.

In the span of just a few months, I’ve noted local races raising awareness of neurologic disorders (multiple sclerosis, Alzheimer’s, stroke, spinal muscular atrophy), cancer (breast, prostate, lung, leukemia, lymphoma, colon, skin, sarcoma, carcinoid), infectious disease (HIV/AIDS), and other medical conditions or causes (cystic fibrosis, cleft palate, pre-eclampsia, transplant, veterans).

Now, don’t get me wrong: I fully support any fund- or awareness-raising events targeting specific diseases or causes. In fact, if I were only slightly less slothlike, I’d participate in more of them. It’s just that in the grand scheme of things, it seems we are missing the forest through the trees. Finding a cure for cancer will matter little if we can’t deliver that cure in a safe, efficient, high-quality manner. Put another way, we can’t cure cancer patients if our health delivery system kills them first.

Seeing the Forest

And kill them we do. Now, you may not like the word “kill,” and certainly it makes me uncomfortable, but what other word better characterizes the situation? Medical errors result in up to 200,000 preventable deaths per year, according to the recent HealthGrades patient safety report.¹ This study reviewed Medicare data from all 50 states and found a mortality rate that was nearly double that reported in the seminal 1999 Institute of Medicine report (44,000-98,000; extrapolated from data in three states).²

And these are just deaths in hospitals; no mention is made of community or residential deaths from medical error. These data also don’t account for the pain and suffering left in the wake of the estimated 15 million annual episodes of harm (that’s 40,000 per day!).

In the end, the World Health Organization (WHO) estimates that 10% of hospital stays involve a serious, preventable, adverse event. Which of the 10 patients you’ll see tomorrow will suffer that serious, PREVENTABLE harm?

Using a conservative average of the two reports, roughly 100,000 people die annually from hospital-based medical errors. This slots medical error as the sixth-most-common cause of death in the U.S., trailing only heart disease (616,067), cancer (562,875), stroke (135,952), chronic lower respiratory disease (127,924), and accidents (123,706). If we use the 200,000 estimate, then error trails only the heart and cancer as a cause of death. And, in terms of individual cancers, only the lung (156,940) kills as many Americans as medical errors. Colorectal (49,380), breast (39,970), and prostate (33,660) don’t even come close.

Yet these data appear to be lost on the legions of race organizers. A Web search uncovered not a single organized race event trying to counter the perils of medical error. No Lance Armstrong, no Katie Couric, no Jerry Lewis. Nothing.

Thankfully, these data are not lost on the ones who bear the brunt of these errors. A Commonwealth survey reported that 22% of respondents were aware of a medical error in care provided to them or their family. Another paper following the release of the IOM report put the number at 42%.^3,4

Still, nary a race “K” has been devoted to reducing medical errors.

Harriers Against Harm

As the finish line draws near, I note that the overhead scoreboard has taken on the appearance of the national debt clock in Manhattan—a large number rapidly getting larger. The replenishment table is littered with crumpled Dixie cups, the music has drifted, and the crowd has dwindled to a handful of volunteers, many of whom tap their toes awaiting my finish.

I wonder what it’ll take. If 12,000 people with spinal muscular atrophy is enough to convene a race, what of the millions of people harmed annually by medical errors? How many more have to die before patient safety becomes an issue, becomes it’s own cause, gets it own fun run?

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

References

1. HealthGrades Eighth Annual Report on Patient Safety in American Hospitals Study. Available at: www.healthgrades.com. Published March 2011. Accessed Aug. 31, 2011.
2. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
3. The Commonwealth Fund 2002 Annual Report. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Content/Annual-Reports/2002-Annual-Report.aspx. Accessed Sept. 9, 2011.
4. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933-1940.

It was when my lung fell out that it hit me. No, come to think of it, it was before that, when a scorpion struck my left calf. Or it might have been when my heart exploded. No, it was earlier than that—probably around the time my right lower abdominal quadrant was gutted by that wild boar. No, actually, it was even earlier than that. Somewhere around the time I pulled my 204th muscle. Yeah, that was it. That’s when I first wondered why there is no “fun run” for safety.

Truth be told, there was no de-lunging, scorpions, cardiac explosion, or wild-boar-goring. It just felt like that. The reason: I was running. The occasion: an annual fun (?) run to support Crohn’s disease and ulcerative colitis. Why I, an out-of-shape specimen blessed with a superhero-like affinity for both chips and the couch, should be pounding the pavement early on a Saturday morning is a case study in wifely nagging.

And misplaced healthcare priorities.

You see, I have neither Crohn’s nor ulcerative colitis, have no friends or family members with them, and, frankly, rarely even provide care for patients with these diseases. What I do have is a gastroenterologist for a wife. A gastroenterologist who passionately supports gastroenterological problems; a gastroenterologist who doesn’t herself like to participate in fun runs; a gastroenterologist who relishes, apparently, seeing her husband sweat lactate while testing the anaerobic limits of the human organism. This was the nagging part.

As the gun reported at 7:30 a.m., there I was, fidgeting nervously at the starting line in a moth-eaten cotton tee from the last road race I had run—in 1989—while those around me gave my too-short, reversible, blue-and-white gym shorts the up-and-down. Cotton socks crotched, feet pre-blistered, I departed, feeling good—for the first four meters.

The next 4.99 kilometers proved slightly more daunting—providing an abundance of K’s to ponder the misplaced healthcare priorities part.

Running in The Trees

After I expertly buried the first 100-meter downhill, the race entered a well-worn, tree-lined footpath. I was shocked by both the splendor of the environs as well as the hordes of people passing me. I was comfortable with the concept of the taut young adults leaving me in their dust and, even, sort of, the superiorly fit elders. The pre-teens were more unsettling. As were the walkers—especially the walker using a walker.

It’s interesting, the relationship between road races and medical diseases. It’s not surprising, really, that generally healthy specimens would band together and use exercise as a weapon against disease—it’s actually quite noble. And common. My guess is your hometown counts numerous foot, bike, and foot-and-bike races supporting the eradication of myriad medical maladies.

In the span of just a few months, I’ve noted local races raising awareness of neurologic disorders (multiple sclerosis, Alzheimer’s, stroke, spinal muscular atrophy), cancer (breast, prostate, lung, leukemia, lymphoma, colon, skin, sarcoma, carcinoid), infectious disease (HIV/AIDS), and other medical conditions or causes (cystic fibrosis, cleft palate, pre-eclampsia, transplant, veterans).

Now, don’t get me wrong: I fully support any fund- or awareness-raising events targeting specific diseases or causes. In fact, if I were only slightly less slothlike, I’d participate in more of them. It’s just that in the grand scheme of things, it seems we are missing the forest through the trees. Finding a cure for cancer will matter little if we can’t deliver that cure in a safe, efficient, high-quality manner. Put another way, we can’t cure cancer patients if our health delivery system kills them first.

Seeing the Forest

And kill them we do. Now, you may not like the word “kill,” and certainly it makes me uncomfortable, but what other word better characterizes the situation? Medical errors result in up to 200,000 preventable deaths per year, according to the recent HealthGrades patient safety report.¹ This study reviewed Medicare data from all 50 states and found a mortality rate that was nearly double that reported in the seminal 1999 Institute of Medicine report (44,000-98,000; extrapolated from data in three states).²

And these are just deaths in hospitals; no mention is made of community or residential deaths from medical error. These data also don’t account for the pain and suffering left in the wake of the estimated 15 million annual episodes of harm (that’s 40,000 per day!).

In the end, the World Health Organization (WHO) estimates that 10% of hospital stays involve a serious, preventable, adverse event. Which of the 10 patients you’ll see tomorrow will suffer that serious, PREVENTABLE harm?

Using a conservative average of the two reports, roughly 100,000 people die annually from hospital-based medical errors. This slots medical error as the sixth-most-common cause of death in the U.S., trailing only heart disease (616,067), cancer (562,875), stroke (135,952), chronic lower respiratory disease (127,924), and accidents (123,706). If we use the 200,000 estimate, then error trails only the heart and cancer as a cause of death. And, in terms of individual cancers, only the lung (156,940) kills as many Americans as medical errors. Colorectal (49,380), breast (39,970), and prostate (33,660) don’t even come close.

Yet these data appear to be lost on the legions of race organizers. A Web search uncovered not a single organized race event trying to counter the perils of medical error. No Lance Armstrong, no Katie Couric, no Jerry Lewis. Nothing.

Thankfully, these data are not lost on the ones who bear the brunt of these errors. A Commonwealth survey reported that 22% of respondents were aware of a medical error in care provided to them or their family. Another paper following the release of the IOM report put the number at 42%.^3,4

Still, nary a race “K” has been devoted to reducing medical errors.

Harriers Against Harm

As the finish line draws near, I note that the overhead scoreboard has taken on the appearance of the national debt clock in Manhattan—a large number rapidly getting larger. The replenishment table is littered with crumpled Dixie cups, the music has drifted, and the crowd has dwindled to a handful of volunteers, many of whom tap their toes awaiting my finish.

I wonder what it’ll take. If 12,000 people with spinal muscular atrophy is enough to convene a race, what of the millions of people harmed annually by medical errors? How many more have to die before patient safety becomes an issue, becomes it’s own cause, gets it own fun run?

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

References

1. HealthGrades Eighth Annual Report on Patient Safety in American Hospitals Study. Available at: www.healthgrades.com. Published March 2011. Accessed Aug. 31, 2011.
2. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
3. The Commonwealth Fund 2002 Annual Report. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Content/Annual-Reports/2002-Annual-Report.aspx. Accessed Sept. 9, 2011.
4. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933-1940.

It was when my lung fell out that it hit me. No, come to think of it, it was before that, when a scorpion struck my left calf. Or it might have been when my heart exploded. No, it was earlier than that—probably around the time my right lower abdominal quadrant was gutted by that wild boar. No, actually, it was even earlier than that. Somewhere around the time I pulled my 204th muscle. Yeah, that was it. That’s when I first wondered why there is no “fun run” for safety.

Truth be told, there was no de-lunging, scorpions, cardiac explosion, or wild-boar-goring. It just felt like that. The reason: I was running. The occasion: an annual fun (?) run to support Crohn’s disease and ulcerative colitis. Why I, an out-of-shape specimen blessed with a superhero-like affinity for both chips and the couch, should be pounding the pavement early on a Saturday morning is a case study in wifely nagging.

And misplaced healthcare priorities.

You see, I have neither Crohn’s nor ulcerative colitis, have no friends or family members with them, and, frankly, rarely even provide care for patients with these diseases. What I do have is a gastroenterologist for a wife. A gastroenterologist who passionately supports gastroenterological problems; a gastroenterologist who doesn’t herself like to participate in fun runs; a gastroenterologist who relishes, apparently, seeing her husband sweat lactate while testing the anaerobic limits of the human organism. This was the nagging part.

As the gun reported at 7:30 a.m., there I was, fidgeting nervously at the starting line in a moth-eaten cotton tee from the last road race I had run—in 1989—while those around me gave my too-short, reversible, blue-and-white gym shorts the up-and-down. Cotton socks crotched, feet pre-blistered, I departed, feeling good—for the first four meters.

The next 4.99 kilometers proved slightly more daunting—providing an abundance of K’s to ponder the misplaced healthcare priorities part.

Running in The Trees

After I expertly buried the first 100-meter downhill, the race entered a well-worn, tree-lined footpath. I was shocked by both the splendor of the environs as well as the hordes of people passing me. I was comfortable with the concept of the taut young adults leaving me in their dust and, even, sort of, the superiorly fit elders. The pre-teens were more unsettling. As were the walkers—especially the walker using a walker.

It’s interesting, the relationship between road races and medical diseases. It’s not surprising, really, that generally healthy specimens would band together and use exercise as a weapon against disease—it’s actually quite noble. And common. My guess is your hometown counts numerous foot, bike, and foot-and-bike races supporting the eradication of myriad medical maladies.

In the span of just a few months, I’ve noted local races raising awareness of neurologic disorders (multiple sclerosis, Alzheimer’s, stroke, spinal muscular atrophy), cancer (breast, prostate, lung, leukemia, lymphoma, colon, skin, sarcoma, carcinoid), infectious disease (HIV/AIDS), and other medical conditions or causes (cystic fibrosis, cleft palate, pre-eclampsia, transplant, veterans).

Now, don’t get me wrong: I fully support any fund- or awareness-raising events targeting specific diseases or causes. In fact, if I were only slightly less slothlike, I’d participate in more of them. It’s just that in the grand scheme of things, it seems we are missing the forest through the trees. Finding a cure for cancer will matter little if we can’t deliver that cure in a safe, efficient, high-quality manner. Put another way, we can’t cure cancer patients if our health delivery system kills them first.

Seeing the Forest

And kill them we do. Now, you may not like the word “kill,” and certainly it makes me uncomfortable, but what other word better characterizes the situation? Medical errors result in up to 200,000 preventable deaths per year, according to the recent HealthGrades patient safety report.¹ This study reviewed Medicare data from all 50 states and found a mortality rate that was nearly double that reported in the seminal 1999 Institute of Medicine report (44,000-98,000; extrapolated from data in three states).²

And these are just deaths in hospitals; no mention is made of community or residential deaths from medical error. These data also don’t account for the pain and suffering left in the wake of the estimated 15 million annual episodes of harm (that’s 40,000 per day!).

In the end, the World Health Organization (WHO) estimates that 10% of hospital stays involve a serious, preventable, adverse event. Which of the 10 patients you’ll see tomorrow will suffer that serious, PREVENTABLE harm?

Using a conservative average of the two reports, roughly 100,000 people die annually from hospital-based medical errors. This slots medical error as the sixth-most-common cause of death in the U.S., trailing only heart disease (616,067), cancer (562,875), stroke (135,952), chronic lower respiratory disease (127,924), and accidents (123,706). If we use the 200,000 estimate, then error trails only the heart and cancer as a cause of death. And, in terms of individual cancers, only the lung (156,940) kills as many Americans as medical errors. Colorectal (49,380), breast (39,970), and prostate (33,660) don’t even come close.

Yet these data appear to be lost on the legions of race organizers. A Web search uncovered not a single organized race event trying to counter the perils of medical error. No Lance Armstrong, no Katie Couric, no Jerry Lewis. Nothing.

Thankfully, these data are not lost on the ones who bear the brunt of these errors. A Commonwealth survey reported that 22% of respondents were aware of a medical error in care provided to them or their family. Another paper following the release of the IOM report put the number at 42%.^3,4

Still, nary a race “K” has been devoted to reducing medical errors.

Harriers Against Harm

As the finish line draws near, I note that the overhead scoreboard has taken on the appearance of the national debt clock in Manhattan—a large number rapidly getting larger. The replenishment table is littered with crumpled Dixie cups, the music has drifted, and the crowd has dwindled to a handful of volunteers, many of whom tap their toes awaiting my finish.

I wonder what it’ll take. If 12,000 people with spinal muscular atrophy is enough to convene a race, what of the millions of people harmed annually by medical errors? How many more have to die before patient safety becomes an issue, becomes it’s own cause, gets it own fun run?

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

References

1. HealthGrades Eighth Annual Report on Patient Safety in American Hospitals Study. Available at: www.healthgrades.com. Published March 2011. Accessed Aug. 31, 2011.
2. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
3. The Commonwealth Fund 2002 Annual Report. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Content/Annual-Reports/2002-Annual-Report.aspx. Accessed Sept. 9, 2011.
4. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933-1940.

It’s been a hectic week, as the Annals of Internal Medicine paper regarding hospitalist outcomes was published.¹ I cannot escape the fallout of the paper showing that the hospitalist model is associated with increased costs of care. The Internet, the phone, my email, the radio, the hallways all are abuzz with excitement about the implications of this paper. Everyone, it seems, has an opinion. The viewpoints range from “the article is methodologically flawed” to “yeah, but that data is old and things are different now,” to “I knew the model was bunk” to “it’s time to bring back the traditional model of care.”

Moreover, nobody is afraid to share.

Wherever you stand on this continuum, it isn’t hard to find a supporting opinion. NPR covered it, newspapers reported it, and bloggers blogged it. Thousands of words were typed, printed, tweeted, spoken. However, one word seemed conspicuously absent. That word? Thanks.

The Study

The study authors examined more than 58,000 admissions at 454 hospitals and compared the impact of hospitalist versus PCP care on in-hospital and post-discharge outcomes. Predictably, hospital length of stay (LOS) was shorter (0.64 days) and less costly ($282) with the hospitalist model. This has been shown, albeit generally with more robust outcomes, in nearly all-previous studies. Importantly, however, this study lifted the veil on what happens after discharge—and the findings have rocked the foundation of the HM field.

Hospitalist patients were less likely to follow up with their PCP, more likely to go to a skilled nursing facility, more likely to return to the ED, and had higher rates of 30-day readmission. All of this post-discharge care came with a price tag—$332 more than the PCP model—making the bundled in- and outpatient costs of care about $50 more per patient in the hospitalist model.

And this is where the controversy—and the words—begins. Connecting the earlier discharge, the added SNF utilization, and the higher readmission rate could only mean only one thing to those that favor the traditional model—a cost shift. Clearly hospitalists, motivated by saving money, are shifting the financial costs just beyond the hospital confines, discharging patients so early that they require nursing home and, ultimately, more ED visits and hospital care.

On the other side of the ledger, HM supporters have pointed out that the patients in the two arms were not the same. The HM patients were more likely to be admitted from a nursing home, more comorbid, poorer, and more likely to be admitted on a weekend—all valid points, which are hard to control for in an observational study. They argue that patients in an SNF are, of course, less likely to see their PCP than patients at home and, therefore, more likely to be sent to an ED (and admitted) when issues arise. Perhaps, the argument goes, in this scenario the system is actually working. Without indicators of quality of life and functional status, it’s hard to know that HM patients didn’t do better. Sure, there were more readmissions and it cost more, but perhaps that’s the cost of better, longer-term outcomes.

My take: Let’s move beyond debating the study merits and its implications. HM is here to stay. No matter how much we conjure Osler, we aren’t going back to the traditional model. In the debate we miss the point. Rome is afire; it’s time to stop fiddling.

So, let’s put our preconceived biases, the potential methodological flaws, the conspiratorial overtones, the vitriolic banter, and the fruitless debates behind us. This study was generally well done. It focuses on a (perhaps, the) crucial issue for HM. And its findings are plausible. For that I say “thanks”: for exposing this issue so we can tackle it head on by moving in at least three distinct directions—quality, training, and retraining.

Now let’s put down the fiddle and pick up the extinguisher.

$50: The Price of Quality?

First, I hope this study finally pushes our field beyond the cost discussion. We simply can and should not be a field that is about saving money. Yes, it is great to save money. But more important, we have to enhance the quality and safety of hospital (and post-hospital) care.

The piece missing from the Annals paper is any significant look at quality metrics, beyond perhaps readmission. It is possible, and maybe probable, that hospitalists in this study reduced complications, avoided harm, and improved inpatient mortality. Perhaps this, and not a zeal for too-early discharges, is what fueled the lower hospital cost and shorter LOS.

How much is that worth? It’s hard to say, but I’d venture much more than the $50 more per patient associated with the hospitalist model. Quality, even at higher costs, needs to be our primary focus moving forward. We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal. I’d also argue that we include the post-discharge period in our quality reach.

More QI, Less MEN

We cannot continue to train square pegs and struggle to cram them into round holes. We need more systems thinkers. We do a tremendous job teaching our students and residents about the interplay of pathophysiology and pharmacology, but spend very little time with the interplay between our patients and the system. We simply must triage process improvement, quality, safety, and efficiency training closer to the top of our medical curricula.

As such, it shouldn’t be that surprising that two groups of providers with the exact same background and training should have similar outcomes as seen in this study. The reality is that these providers came from very similar training backgrounds. Yes, they have chosen different practice models, but we all learned how to treat pneumonia and heart failure. It’s not about the model as much as what you do with the model. Cohorting patients to providers who just care for hospitalized patients will lead to efficiencies, but if we want to fundamentally improve patient outcomes, both during and after their hospital stay, we need to train hospitalists to transform that model through systematic process improvement.

And I firmly believe that hospitalists should lead this sea change. Our teaching brethren are perfectly positioned to develop hospitalist-focused training models that better prepare future hospitalists to fundamentally improve not just transitions of care but indeed all systems of care. Training that emphasizes systems thinking, mentored process improvement, and patient safety across the continuum of care.

BOOSTing Outcomes

This paper highlights HM’s Achilles’ heel. It has always been transitions of care—specifically, communication with PCPs. HM is by its very nature a fractured care model. And that discontinuity results in information drop on transitions. A PCP who knows a patient and admits and follows them after discharge is better positioned to reduce readmissions because there is no information drop in that model. The success of the HM model hinges on hospitalists efficiently and effectively approximating that level of knowledge transfer to PCPs. And to be honest, we don’t need an NIH-funded study to tell us that we have not been doing a great job with this.

This is not necessarily from a lack of effort but rather because we lack systems that simplify information transfer on transitions. It is incumbent these systems be built. It is incumbent we lead this. Whether you choose Project BOOST, Project RED, or a homegrown solution, it is no longer acceptable to ignore the transitions of care issue.

And with that I’ve just typed my 1,319th word about an article that has already commanded too many words. Don’t get me wrong, the discussion is important, and for that we must thank the study’s authors. But it’s time to move beyond the discussion, the debate, the words.

It’s time to turn words into deeds.

Dr. Glasheen is physician editor of The Hospitalist.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

It’s been a hectic week, as the Annals of Internal Medicine paper regarding hospitalist outcomes was published.¹ I cannot escape the fallout of the paper showing that the hospitalist model is associated with increased costs of care. The Internet, the phone, my email, the radio, the hallways all are abuzz with excitement about the implications of this paper. Everyone, it seems, has an opinion. The viewpoints range from “the article is methodologically flawed” to “yeah, but that data is old and things are different now,” to “I knew the model was bunk” to “it’s time to bring back the traditional model of care.”

Moreover, nobody is afraid to share.

Wherever you stand on this continuum, it isn’t hard to find a supporting opinion. NPR covered it, newspapers reported it, and bloggers blogged it. Thousands of words were typed, printed, tweeted, spoken. However, one word seemed conspicuously absent. That word? Thanks.

The Study

The study authors examined more than 58,000 admissions at 454 hospitals and compared the impact of hospitalist versus PCP care on in-hospital and post-discharge outcomes. Predictably, hospital length of stay (LOS) was shorter (0.64 days) and less costly ($282) with the hospitalist model. This has been shown, albeit generally with more robust outcomes, in nearly all-previous studies. Importantly, however, this study lifted the veil on what happens after discharge—and the findings have rocked the foundation of the HM field.

Hospitalist patients were less likely to follow up with their PCP, more likely to go to a skilled nursing facility, more likely to return to the ED, and had higher rates of 30-day readmission. All of this post-discharge care came with a price tag—$332 more than the PCP model—making the bundled in- and outpatient costs of care about $50 more per patient in the hospitalist model.

And this is where the controversy—and the words—begins. Connecting the earlier discharge, the added SNF utilization, and the higher readmission rate could only mean only one thing to those that favor the traditional model—a cost shift. Clearly hospitalists, motivated by saving money, are shifting the financial costs just beyond the hospital confines, discharging patients so early that they require nursing home and, ultimately, more ED visits and hospital care.

On the other side of the ledger, HM supporters have pointed out that the patients in the two arms were not the same. The HM patients were more likely to be admitted from a nursing home, more comorbid, poorer, and more likely to be admitted on a weekend—all valid points, which are hard to control for in an observational study. They argue that patients in an SNF are, of course, less likely to see their PCP than patients at home and, therefore, more likely to be sent to an ED (and admitted) when issues arise. Perhaps, the argument goes, in this scenario the system is actually working. Without indicators of quality of life and functional status, it’s hard to know that HM patients didn’t do better. Sure, there were more readmissions and it cost more, but perhaps that’s the cost of better, longer-term outcomes.

My take: Let’s move beyond debating the study merits and its implications. HM is here to stay. No matter how much we conjure Osler, we aren’t going back to the traditional model. In the debate we miss the point. Rome is afire; it’s time to stop fiddling.

So, let’s put our preconceived biases, the potential methodological flaws, the conspiratorial overtones, the vitriolic banter, and the fruitless debates behind us. This study was generally well done. It focuses on a (perhaps, the) crucial issue for HM. And its findings are plausible. For that I say “thanks”: for exposing this issue so we can tackle it head on by moving in at least three distinct directions—quality, training, and retraining.

Now let’s put down the fiddle and pick up the extinguisher.

$50: The Price of Quality?

First, I hope this study finally pushes our field beyond the cost discussion. We simply can and should not be a field that is about saving money. Yes, it is great to save money. But more important, we have to enhance the quality and safety of hospital (and post-hospital) care.

The piece missing from the Annals paper is any significant look at quality metrics, beyond perhaps readmission. It is possible, and maybe probable, that hospitalists in this study reduced complications, avoided harm, and improved inpatient mortality. Perhaps this, and not a zeal for too-early discharges, is what fueled the lower hospital cost and shorter LOS.

How much is that worth? It’s hard to say, but I’d venture much more than the $50 more per patient associated with the hospitalist model. Quality, even at higher costs, needs to be our primary focus moving forward. We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal. I’d also argue that we include the post-discharge period in our quality reach.

More QI, Less MEN

We cannot continue to train square pegs and struggle to cram them into round holes. We need more systems thinkers. We do a tremendous job teaching our students and residents about the interplay of pathophysiology and pharmacology, but spend very little time with the interplay between our patients and the system. We simply must triage process improvement, quality, safety, and efficiency training closer to the top of our medical curricula.

As such, it shouldn’t be that surprising that two groups of providers with the exact same background and training should have similar outcomes as seen in this study. The reality is that these providers came from very similar training backgrounds. Yes, they have chosen different practice models, but we all learned how to treat pneumonia and heart failure. It’s not about the model as much as what you do with the model. Cohorting patients to providers who just care for hospitalized patients will lead to efficiencies, but if we want to fundamentally improve patient outcomes, both during and after their hospital stay, we need to train hospitalists to transform that model through systematic process improvement.

And I firmly believe that hospitalists should lead this sea change. Our teaching brethren are perfectly positioned to develop hospitalist-focused training models that better prepare future hospitalists to fundamentally improve not just transitions of care but indeed all systems of care. Training that emphasizes systems thinking, mentored process improvement, and patient safety across the continuum of care.

BOOSTing Outcomes

This paper highlights HM’s Achilles’ heel. It has always been transitions of care—specifically, communication with PCPs. HM is by its very nature a fractured care model. And that discontinuity results in information drop on transitions. A PCP who knows a patient and admits and follows them after discharge is better positioned to reduce readmissions because there is no information drop in that model. The success of the HM model hinges on hospitalists efficiently and effectively approximating that level of knowledge transfer to PCPs. And to be honest, we don’t need an NIH-funded study to tell us that we have not been doing a great job with this.

This is not necessarily from a lack of effort but rather because we lack systems that simplify information transfer on transitions. It is incumbent these systems be built. It is incumbent we lead this. Whether you choose Project BOOST, Project RED, or a homegrown solution, it is no longer acceptable to ignore the transitions of care issue.

And with that I’ve just typed my 1,319th word about an article that has already commanded too many words. Don’t get me wrong, the discussion is important, and for that we must thank the study’s authors. But it’s time to move beyond the discussion, the debate, the words.

It’s time to turn words into deeds.

Dr. Glasheen is physician editor of The Hospitalist.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

It’s been a hectic week, as the Annals of Internal Medicine paper regarding hospitalist outcomes was published.¹ I cannot escape the fallout of the paper showing that the hospitalist model is associated with increased costs of care. The Internet, the phone, my email, the radio, the hallways all are abuzz with excitement about the implications of this paper. Everyone, it seems, has an opinion. The viewpoints range from “the article is methodologically flawed” to “yeah, but that data is old and things are different now,” to “I knew the model was bunk” to “it’s time to bring back the traditional model of care.”

Moreover, nobody is afraid to share.

Wherever you stand on this continuum, it isn’t hard to find a supporting opinion. NPR covered it, newspapers reported it, and bloggers blogged it. Thousands of words were typed, printed, tweeted, spoken. However, one word seemed conspicuously absent. That word? Thanks.

The Study

The study authors examined more than 58,000 admissions at 454 hospitals and compared the impact of hospitalist versus PCP care on in-hospital and post-discharge outcomes. Predictably, hospital length of stay (LOS) was shorter (0.64 days) and less costly ($282) with the hospitalist model. This has been shown, albeit generally with more robust outcomes, in nearly all-previous studies. Importantly, however, this study lifted the veil on what happens after discharge—and the findings have rocked the foundation of the HM field.

Hospitalist patients were less likely to follow up with their PCP, more likely to go to a skilled nursing facility, more likely to return to the ED, and had higher rates of 30-day readmission. All of this post-discharge care came with a price tag—$332 more than the PCP model—making the bundled in- and outpatient costs of care about $50 more per patient in the hospitalist model.

And this is where the controversy—and the words—begins. Connecting the earlier discharge, the added SNF utilization, and the higher readmission rate could only mean only one thing to those that favor the traditional model—a cost shift. Clearly hospitalists, motivated by saving money, are shifting the financial costs just beyond the hospital confines, discharging patients so early that they require nursing home and, ultimately, more ED visits and hospital care.

On the other side of the ledger, HM supporters have pointed out that the patients in the two arms were not the same. The HM patients were more likely to be admitted from a nursing home, more comorbid, poorer, and more likely to be admitted on a weekend—all valid points, which are hard to control for in an observational study. They argue that patients in an SNF are, of course, less likely to see their PCP than patients at home and, therefore, more likely to be sent to an ED (and admitted) when issues arise. Perhaps, the argument goes, in this scenario the system is actually working. Without indicators of quality of life and functional status, it’s hard to know that HM patients didn’t do better. Sure, there were more readmissions and it cost more, but perhaps that’s the cost of better, longer-term outcomes.

My take: Let’s move beyond debating the study merits and its implications. HM is here to stay. No matter how much we conjure Osler, we aren’t going back to the traditional model. In the debate we miss the point. Rome is afire; it’s time to stop fiddling.

So, let’s put our preconceived biases, the potential methodological flaws, the conspiratorial overtones, the vitriolic banter, and the fruitless debates behind us. This study was generally well done. It focuses on a (perhaps, the) crucial issue for HM. And its findings are plausible. For that I say “thanks”: for exposing this issue so we can tackle it head on by moving in at least three distinct directions—quality, training, and retraining.

Now let’s put down the fiddle and pick up the extinguisher.

$50: The Price of Quality?

First, I hope this study finally pushes our field beyond the cost discussion. We simply can and should not be a field that is about saving money. Yes, it is great to save money. But more important, we have to enhance the quality and safety of hospital (and post-hospital) care.

The piece missing from the Annals paper is any significant look at quality metrics, beyond perhaps readmission. It is possible, and maybe probable, that hospitalists in this study reduced complications, avoided harm, and improved inpatient mortality. Perhaps this, and not a zeal for too-early discharges, is what fueled the lower hospital cost and shorter LOS.

How much is that worth? It’s hard to say, but I’d venture much more than the $50 more per patient associated with the hospitalist model. Quality, even at higher costs, needs to be our primary focus moving forward. We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal. I’d also argue that we include the post-discharge period in our quality reach.

More QI, Less MEN

We cannot continue to train square pegs and struggle to cram them into round holes. We need more systems thinkers. We do a tremendous job teaching our students and residents about the interplay of pathophysiology and pharmacology, but spend very little time with the interplay between our patients and the system. We simply must triage process improvement, quality, safety, and efficiency training closer to the top of our medical curricula.

As such, it shouldn’t be that surprising that two groups of providers with the exact same background and training should have similar outcomes as seen in this study. The reality is that these providers came from very similar training backgrounds. Yes, they have chosen different practice models, but we all learned how to treat pneumonia and heart failure. It’s not about the model as much as what you do with the model. Cohorting patients to providers who just care for hospitalized patients will lead to efficiencies, but if we want to fundamentally improve patient outcomes, both during and after their hospital stay, we need to train hospitalists to transform that model through systematic process improvement.

And I firmly believe that hospitalists should lead this sea change. Our teaching brethren are perfectly positioned to develop hospitalist-focused training models that better prepare future hospitalists to fundamentally improve not just transitions of care but indeed all systems of care. Training that emphasizes systems thinking, mentored process improvement, and patient safety across the continuum of care.

BOOSTing Outcomes

This paper highlights HM’s Achilles’ heel. It has always been transitions of care—specifically, communication with PCPs. HM is by its very nature a fractured care model. And that discontinuity results in information drop on transitions. A PCP who knows a patient and admits and follows them after discharge is better positioned to reduce readmissions because there is no information drop in that model. The success of the HM model hinges on hospitalists efficiently and effectively approximating that level of knowledge transfer to PCPs. And to be honest, we don’t need an NIH-funded study to tell us that we have not been doing a great job with this.

This is not necessarily from a lack of effort but rather because we lack systems that simplify information transfer on transitions. It is incumbent these systems be built. It is incumbent we lead this. Whether you choose Project BOOST, Project RED, or a homegrown solution, it is no longer acceptable to ignore the transitions of care issue.

And with that I’ve just typed my 1,319th word about an article that has already commanded too many words. Don’t get me wrong, the discussion is important, and for that we must thank the study’s authors. But it’s time to move beyond the discussion, the debate, the words.

It’s time to turn words into deeds.

Dr. Glasheen is physician editor of The Hospitalist.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.¹

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.²

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.^3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.⁵

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.¹

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.²

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.^3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.⁵

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.¹

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.²

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.^3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.⁵

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

Question: Before hospitalists, who cared for hospitalized patients?

Answer: Generalists—in other words, internists, family physicians, pediatricians.

Q: How much did that system cost hospitals?

A: Nothing, or very little. In some cases, support dollars were available for weekend, night, or uninsured patient coverage, but by and large this system cost hospitals little. Physicians admitted their patients to the hospital because the alternatives (sending a hypoxic pneumonia patient home from clinic, turning out the office lights and hoping the patient survived the night, or bringing the patient home with them) offered uncomfortable ethical, malpractice, or alimony consequences. So doctors admitted these patients to the hospital and visited them daily.

Q: The average amount of support per hospitalist is $131,564, or about $1.7 million per HM group seeing adult patients. The bulk of those dollars come from the hospital. If we assume that the people running hospitals are smart, then why would those smart businesspeople pay $1.7 million for something they used to get for free?

A: Because there is something they get in return for that money. Or, perhaps, something they think they are getting in return for those dollars.

Q: What?

A: I often go through this exercise with the residents in our hospitalist training program when we discuss the drivers of the HM movement. I usually discuss the reasons why a hospital should fund these groups; it always seems like such a no-brainer to me.

Enter a recent news item from Montana. The story from the Helena Independent Record (see “Unsustainable Growth?” p. 1) noted that a multispecialty group practice in Helena announced they were no longer admitting their patients to a local hospital in protest over a new hospital policy to charge the clinic practice. The fee was to defray some of the costs of the HM program. A hospital representative was quoted as saying “physicians are responsible for obtaining hospital coverage for their own patients, not the hospital.”

I can’t really argue with the logic of that statement. Surely a clinic has responsibility to ensure that their patients get cared for while they are inpatients. If an internist is going to see a patient in the clinic and admit them to the hospital, shouldn’t an internist then see the patient in the hospital?

If I’m a hospital CEO, the answer is no.

To retrench a bit, yes, I’d want a board-certified internal-medicine (or pediatric or family medicine) physician to see the hospitalized patient. But in the process, I wouldn’t want them to only practice internal medicine. That was the model hospitals had 25 years ago—a model that cost them very little, a model that they played a large part in exterminating. The fact that most hospitals are willing to pay millions or more per year to not have that system tells me that they don’t want that system.

Q: So, what do hospitals want?

A: Hospitalists, not internists in the hospital.

What’s the difference? Well, it’s a perception issue. Many, if not most, believe that all it takes to be a great hospitalist is to show up for your shift, provide great care to your 15 patients, and go home. That is, the job is defined by the clinical effort—the internist part. Although there is tremendous benefit to this and I recognize its importance (and let’s not forget the weekend, night, and holiday coverage), this sells us short and puts our financial stability in peril.

To be great, to best help our patients, to give our hospitals what they want and need, we have to evolve from “internists in the hospital” to hospitalists. Hospitalists are defined not by our clinical effort but rather by our nonclinical effort. This is what hospitals are paying $1.7 million per year for. They had the internist in the hospital model and chose to pay more—they chose the hospitalist model.

To be a great hospitalist group means embracing the nonclinical work that envelops the clinical practice—the process and quality improvement (QI). That is, fundamentally changing the unsafe systems that surround our patients. Making them safer, more efficient and of higher quality.

This takes time.

Time = Money

It takes time to implement a QI project to reduce central line infections in the ICU. Or to develop and implement a VTE prophylaxis order set or an insulin or heparin drip protocol. Or to work closely with nursing to reduce falls on a medical unit. It takes time to be at the pneumonia core measures meeting every Monday at 7 a.m. and the hospital credentialing committee meeting every other Friday at 3 p.m. It also takes time to implement a new electronic health record or roll out the new LEAN project to reduce ED wait times.

This takes time, effort, and bandwidth—the kind that can’t be shoehorned into the average clinical day. This is work that needs to be done primarily during nonclinical hours. It’s the kind of work that defines HM as a field; the kind of work that increasingly determines your hospital’s bottom line; the kind of work that has tremendous value; the kind of work that requires remuneration.

In paying for the hospitalist model, your hospital is paying for the clinical (internist) and nonclinical (hospitalist) work you do. The $1.7 million per year is not a subsidy they pay to keep you in business. It’s the price they must pay to compensate your group for all the nonclinical work you do around quality, safety, efficiency, and leadership.

Q: But what if my group isn’t doing these kinds of things?

A: Then your hospital funding is at risk. The Montana story addresses just such a scenario. Clearly the hospital C-suite in this instance only valued (or was presented with) clinical work. Therefore, they felt that others should subsidize the hospitalist salaries—in this case, the clinic. I don’t know the particulars of this case but deduce this because it would be ludicrous to expect the clinic to pay for the part of the hospitalists’ time spent improving the hospital’s systems of care.

Writing the Final Chapter

At the core of the HM funding model is the concept of subsidy versus compensation. If we are only providing clinical care, then the offset dollars from the hospital to support our salaries is functionally a subsidy—a dollar amount to make up for our collections shortfall. However, if it is support for the nonclinical work we are doing, then it is compensation.

As the story of hospitalist funding is written, the report from Montana should serve as a cautionary tale. Hospital financial pressures likely will focus more scrutiny on the hospitalist financial support model. And as this story plays out, HM groups will be expected to bring more to the table than patient care.

Those that do will live happily ever after.

Those that don’t will be forced to answer the tough question: What’s the difference between an internist in the hospital and a hospitalist? If the answer is nothing, that story will have a decidedly and predictably less happy ending. 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.

Question: Before hospitalists, who cared for hospitalized patients?

Answer: Generalists—in other words, internists, family physicians, pediatricians.

Q: How much did that system cost hospitals?

A: Nothing, or very little. In some cases, support dollars were available for weekend, night, or uninsured patient coverage, but by and large this system cost hospitals little. Physicians admitted their patients to the hospital because the alternatives (sending a hypoxic pneumonia patient home from clinic, turning out the office lights and hoping the patient survived the night, or bringing the patient home with them) offered uncomfortable ethical, malpractice, or alimony consequences. So doctors admitted these patients to the hospital and visited them daily.

Q: The average amount of support per hospitalist is $131,564, or about $1.7 million per HM group seeing adult patients. The bulk of those dollars come from the hospital. If we assume that the people running hospitals are smart, then why would those smart businesspeople pay $1.7 million for something they used to get for free?

A: Because there is something they get in return for that money. Or, perhaps, something they think they are getting in return for those dollars.

Q: What?

A: I often go through this exercise with the residents in our hospitalist training program when we discuss the drivers of the HM movement. I usually discuss the reasons why a hospital should fund these groups; it always seems like such a no-brainer to me.

Enter a recent news item from Montana. The story from the Helena Independent Record (see “Unsustainable Growth?” p. 1) noted that a multispecialty group practice in Helena announced they were no longer admitting their patients to a local hospital in protest over a new hospital policy to charge the clinic practice. The fee was to defray some of the costs of the HM program. A hospital representative was quoted as saying “physicians are responsible for obtaining hospital coverage for their own patients, not the hospital.”

I can’t really argue with the logic of that statement. Surely a clinic has responsibility to ensure that their patients get cared for while they are inpatients. If an internist is going to see a patient in the clinic and admit them to the hospital, shouldn’t an internist then see the patient in the hospital?

If I’m a hospital CEO, the answer is no.

To retrench a bit, yes, I’d want a board-certified internal-medicine (or pediatric or family medicine) physician to see the hospitalized patient. But in the process, I wouldn’t want them to only practice internal medicine. That was the model hospitals had 25 years ago—a model that cost them very little, a model that they played a large part in exterminating. The fact that most hospitals are willing to pay millions or more per year to not have that system tells me that they don’t want that system.

Q: So, what do hospitals want?

A: Hospitalists, not internists in the hospital.

What’s the difference? Well, it’s a perception issue. Many, if not most, believe that all it takes to be a great hospitalist is to show up for your shift, provide great care to your 15 patients, and go home. That is, the job is defined by the clinical effort—the internist part. Although there is tremendous benefit to this and I recognize its importance (and let’s not forget the weekend, night, and holiday coverage), this sells us short and puts our financial stability in peril.

To be great, to best help our patients, to give our hospitals what they want and need, we have to evolve from “internists in the hospital” to hospitalists. Hospitalists are defined not by our clinical effort but rather by our nonclinical effort. This is what hospitals are paying $1.7 million per year for. They had the internist in the hospital model and chose to pay more—they chose the hospitalist model.

To be a great hospitalist group means embracing the nonclinical work that envelops the clinical practice—the process and quality improvement (QI). That is, fundamentally changing the unsafe systems that surround our patients. Making them safer, more efficient and of higher quality.

This takes time.

Time = Money

It takes time to implement a QI project to reduce central line infections in the ICU. Or to develop and implement a VTE prophylaxis order set or an insulin or heparin drip protocol. Or to work closely with nursing to reduce falls on a medical unit. It takes time to be at the pneumonia core measures meeting every Monday at 7 a.m. and the hospital credentialing committee meeting every other Friday at 3 p.m. It also takes time to implement a new electronic health record or roll out the new LEAN project to reduce ED wait times.

This takes time, effort, and bandwidth—the kind that can’t be shoehorned into the average clinical day. This is work that needs to be done primarily during nonclinical hours. It’s the kind of work that defines HM as a field; the kind of work that increasingly determines your hospital’s bottom line; the kind of work that has tremendous value; the kind of work that requires remuneration.

In paying for the hospitalist model, your hospital is paying for the clinical (internist) and nonclinical (hospitalist) work you do. The $1.7 million per year is not a subsidy they pay to keep you in business. It’s the price they must pay to compensate your group for all the nonclinical work you do around quality, safety, efficiency, and leadership.

Q: But what if my group isn’t doing these kinds of things?

A: Then your hospital funding is at risk. The Montana story addresses just such a scenario. Clearly the hospital C-suite in this instance only valued (or was presented with) clinical work. Therefore, they felt that others should subsidize the hospitalist salaries—in this case, the clinic. I don’t know the particulars of this case but deduce this because it would be ludicrous to expect the clinic to pay for the part of the hospitalists’ time spent improving the hospital’s systems of care.

Writing the Final Chapter

At the core of the HM funding model is the concept of subsidy versus compensation. If we are only providing clinical care, then the offset dollars from the hospital to support our salaries is functionally a subsidy—a dollar amount to make up for our collections shortfall. However, if it is support for the nonclinical work we are doing, then it is compensation.

As the story of hospitalist funding is written, the report from Montana should serve as a cautionary tale. Hospital financial pressures likely will focus more scrutiny on the hospitalist financial support model. And as this story plays out, HM groups will be expected to bring more to the table than patient care.

Those that do will live happily ever after.

Those that don’t will be forced to answer the tough question: What’s the difference between an internist in the hospital and a hospitalist? If the answer is nothing, that story will have a decidedly and predictably less happy ending. 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.

Question: Before hospitalists, who cared for hospitalized patients?

Answer: Generalists—in other words, internists, family physicians, pediatricians.

Q: How much did that system cost hospitals?

A: Nothing, or very little. In some cases, support dollars were available for weekend, night, or uninsured patient coverage, but by and large this system cost hospitals little. Physicians admitted their patients to the hospital because the alternatives (sending a hypoxic pneumonia patient home from clinic, turning out the office lights and hoping the patient survived the night, or bringing the patient home with them) offered uncomfortable ethical, malpractice, or alimony consequences. So doctors admitted these patients to the hospital and visited them daily.

Q: The average amount of support per hospitalist is $131,564, or about $1.7 million per HM group seeing adult patients. The bulk of those dollars come from the hospital. If we assume that the people running hospitals are smart, then why would those smart businesspeople pay $1.7 million for something they used to get for free?

A: Because there is something they get in return for that money. Or, perhaps, something they think they are getting in return for those dollars.

Q: What?

A: I often go through this exercise with the residents in our hospitalist training program when we discuss the drivers of the HM movement. I usually discuss the reasons why a hospital should fund these groups; it always seems like such a no-brainer to me.

Enter a recent news item from Montana. The story from the Helena Independent Record (see “Unsustainable Growth?” p. 1) noted that a multispecialty group practice in Helena announced they were no longer admitting their patients to a local hospital in protest over a new hospital policy to charge the clinic practice. The fee was to defray some of the costs of the HM program. A hospital representative was quoted as saying “physicians are responsible for obtaining hospital coverage for their own patients, not the hospital.”

I can’t really argue with the logic of that statement. Surely a clinic has responsibility to ensure that their patients get cared for while they are inpatients. If an internist is going to see a patient in the clinic and admit them to the hospital, shouldn’t an internist then see the patient in the hospital?

If I’m a hospital CEO, the answer is no.

To retrench a bit, yes, I’d want a board-certified internal-medicine (or pediatric or family medicine) physician to see the hospitalized patient. But in the process, I wouldn’t want them to only practice internal medicine. That was the model hospitals had 25 years ago—a model that cost them very little, a model that they played a large part in exterminating. The fact that most hospitals are willing to pay millions or more per year to not have that system tells me that they don’t want that system.

Q: So, what do hospitals want?

A: Hospitalists, not internists in the hospital.

What’s the difference? Well, it’s a perception issue. Many, if not most, believe that all it takes to be a great hospitalist is to show up for your shift, provide great care to your 15 patients, and go home. That is, the job is defined by the clinical effort—the internist part. Although there is tremendous benefit to this and I recognize its importance (and let’s not forget the weekend, night, and holiday coverage), this sells us short and puts our financial stability in peril.

To be great, to best help our patients, to give our hospitals what they want and need, we have to evolve from “internists in the hospital” to hospitalists. Hospitalists are defined not by our clinical effort but rather by our nonclinical effort. This is what hospitals are paying $1.7 million per year for. They had the internist in the hospital model and chose to pay more—they chose the hospitalist model.

To be a great hospitalist group means embracing the nonclinical work that envelops the clinical practice—the process and quality improvement (QI). That is, fundamentally changing the unsafe systems that surround our patients. Making them safer, more efficient and of higher quality.

This takes time.

Time = Money

It takes time to implement a QI project to reduce central line infections in the ICU. Or to develop and implement a VTE prophylaxis order set or an insulin or heparin drip protocol. Or to work closely with nursing to reduce falls on a medical unit. It takes time to be at the pneumonia core measures meeting every Monday at 7 a.m. and the hospital credentialing committee meeting every other Friday at 3 p.m. It also takes time to implement a new electronic health record or roll out the new LEAN project to reduce ED wait times.

This takes time, effort, and bandwidth—the kind that can’t be shoehorned into the average clinical day. This is work that needs to be done primarily during nonclinical hours. It’s the kind of work that defines HM as a field; the kind of work that increasingly determines your hospital’s bottom line; the kind of work that has tremendous value; the kind of work that requires remuneration.

In paying for the hospitalist model, your hospital is paying for the clinical (internist) and nonclinical (hospitalist) work you do. The $1.7 million per year is not a subsidy they pay to keep you in business. It’s the price they must pay to compensate your group for all the nonclinical work you do around quality, safety, efficiency, and leadership.

Q: But what if my group isn’t doing these kinds of things?

A: Then your hospital funding is at risk. The Montana story addresses just such a scenario. Clearly the hospital C-suite in this instance only valued (or was presented with) clinical work. Therefore, they felt that others should subsidize the hospitalist salaries—in this case, the clinic. I don’t know the particulars of this case but deduce this because it would be ludicrous to expect the clinic to pay for the part of the hospitalists’ time spent improving the hospital’s systems of care.

Writing the Final Chapter

At the core of the HM funding model is the concept of subsidy versus compensation. If we are only providing clinical care, then the offset dollars from the hospital to support our salaries is functionally a subsidy—a dollar amount to make up for our collections shortfall. However, if it is support for the nonclinical work we are doing, then it is compensation.

As the story of hospitalist funding is written, the report from Montana should serve as a cautionary tale. Hospital financial pressures likely will focus more scrutiny on the hospitalist financial support model. And as this story plays out, HM groups will be expected to bring more to the table than patient care.

Those that do will live happily ever after.

Those that don’t will be forced to answer the tough question: What’s the difference between an internist in the hospital and a hospitalist? If the answer is nothing, that story will have a decidedly and predictably less happy ending. 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.