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The Family Way
Although the vast majority of physicians who practice hospital medicine in the United States are board certified in internal medicine, about 3% of hospitalists have their certification in family medicine.
How do differences in training, general outlook on the practice of medicine, or other factors affect their roles as hospitalists? Do practitioners of family medicine bring special skills to inpatient care? Why do they choose to become hospitalists instead of community-based family doctors? Does their certification in family practice give them a particular bond with the patient’s primary care doctor who may also be a family practitioner? How do they fit into the hospitalist picture, which is—at least in the U.S.—so dominated by internists?
To find out, we asked six hospitalists certified in family medicine:
- Jasen W. Gundersen, MD, division chief of hospital medicine, University of Massachusetts Memorial Medical Center, and assistant professor, UMass. Medical School, Worcester, Mass.
- Michael Kedansky, MD, lead hospitalist at the Kino Campus of University Physicians Healthcare Hospital in Tucson, Ariz., and clinical assistant professor of family and community medicine at the University of Arizona College of Medicine;
- Elizabeth Chmelik, MD, director of the Inpatient Medical Program at Scott and White University Medical Campus at Texas A&M University in Austin;
- Echo-Marie Enns, MD, a family practice hospitalist at the Peter Lougheed Center in Calgary, Alberta, Canada.
- Felix Aguirre, MD, vice president of medical affairs at IPC-the Hospitalist Company, San Antonio, Texas; and
- Jennifer Cameron, MD, a family medicine hospitalist with Central Texas Hospitalist who practices at St. David’s Hospital, Round Rock, Texas.
Drs. Gundersen, Kedansky, and Chmelik are members of SHM’s Family Practice Task Force.
Training And Decisions
Most of the experts we spoke with agree training influenced their decision to become hospitalists. They cite the diversity of cases in family practice residency (adult, pediatric, and obstetric/gynecologic), which they felt they would also find in hospital medicine.
Dr. Gundersen, chair of SHM’s Family Practice Task Force, suspects internists and family physicians probably share one motivator for opting into hospital medicine: the hospital environment. “Even in residency, I liked my time in the hospital,” Dr. Gundersen says. Echoing that sentiment, Dr. Kedansky says he missed hospital work when he was in community practice.
Family medicine is about people and relationships, says Dr. Chmelik. “You can get that same satisfaction on an inpatient basis,” she says. “I’ve always liked seeing the same patients from day to day. You get instant gratification.”
The higher levels of support and resources available in a hospital environment as opposed to those in a community-based practice appeal to Dr. Enns.
Dr. Gundersen adds that some physicians don’t like all the paperwork office practice entails; others favor the regulated hours of hospital practice. “People often evolve into it as they get more experience,” he says. “They feel that hospital medicine gives them a chance to really make a difference.”
Dr. Cameron agrees about the paperwork. “Out of residency, I became a primary care physician in Tucson,” she says. “When the local hospital group became unexpectedly short-handed, they asked me to fill in on weekends. Once I proved myself with my eagerness and team spirit, they asked me to join their group. The timing was just right: the office management, billings, paperwork, employee issues, and 24/7 schedule were just killing me, and I was ready to try something else.”
Dr. Aguirre says his hospitalist career grew out of his work with a primary care group. His primary aim was standardizing the care of the hospitalized patients in the group.
Whole-Patient View
What special skills do family medicine physicians bring to hospital medicine? The experts quickly pointed out that though training and backgrounds might differ somewhat between internists and family medicine hospitalists they view their respective skills as complementary.
“Family medicine physicians bring a wider breadth of general knowledge in more medical areas than a traditional internal medicine physician, but an internal medicine physician is expected to have a greater depth of knowledge in general adult medicine, which is the current mainstay of hospital medicine,” says Dr. Aguirre. But he suggests that the knowledge base tends to equalize with experience as internal medicine (IM) and family medicine hospitalists cover each other.
However, he also believes a family physician initially brings more knowledge and practical experience in gynecology, behavioral science, pediatric, orthopedic, and family medicine. “These experiences can be especially useful when crafting hospitalist programs to serve these specific target audiences and to help staff pediatric or IM/pediatric hospitalist programs as well,” he says.
Family medicine covers a lot of bases, these experts say. “Family medicine hospitalists have training in family dynamics, end-of-life issues, and family counseling,” says Dr. Chmelik. “These skills frequently come into play with hospitalized patients.” For Dr. Kedansky, family medicine residency training focuses on treating the whole patient “from birth to death.”
Dr. Gundersen knows how broad that role is. “We have the ability to treat adult, newborn, pediatric, and obstetric/gynecologic patients,” he says. “Some family medicine hospitalists even do labor management,” he says.
According to him, a family practice hospitalist gives a hospital special value because one hospitalist can take care of children as well as adults.
Community is important in the hospitalist-patient relationship. “Family practitioners learn how patients fit into the community,” says Dr. Enns. “We can picture patients in a home setting. This helps us in getting patients ready for discharge.”
The outpatient perspective gives family practitioners more foresight, says Dr. Cameron. Family practitioners “see possible roadblocks to a successful discharge to the home and are more willing to jump through the necessary hoops to ensure things go as planned once the patient is discharged,” she says. “As prior outpatient physicians, we know the frustration of having a patient just discharged from the hospital land in our clinic Monday morning with many issues unaddressed.”
Many family physicians had office practices before becoming hospitalists. “We understand how the continuum works,” says Dr. Kedansky.
—Elizabeth Chmelik, MD, director of the Inpatient Medical Program at Scott and White University Medical Campus at Texas A&M University, Austin
Bond with Primary Docs
Does belonging to the same “fraternity”—family medicine—create a special relationship between a primary care doctor and a hospitalist with a similar background and training?
From the Canadian perspective, Dr. Enns thinks it may. She says resource constraints may apply to the primary care physician working in the community. “When I am treating a patient, I sometimes find a condition that is unrelated to the patient’s hospitalization,” she says. “I have better access to resources, so I might be able to accomplish a lot for my colleague. I’ll call and ask if the doctor would like me to run an appropriate test, for example. Usually the primary care doctor is extremely grateful for the help.”
In the U.S., Dr. Gundersen suggests that the specialty of neither the primary care doctor nor the hospitalist is particularly important. “Continuity of care is the critical thing,” he says. “The point is to have good communication and a smooth handoff back to the primary care doctor.”
Dr. Kedansky agrees on the necessity for good communication but feels a greater sense of connectivity with the primary care physician, partly because he has been one. “I also know many of the docs personally, so that helps,” he says.
For Drs. Aguirre and Cameron, having worked as a primary care physician helps them empathize with their concerns about continuity and quality of care.
“I have been in their shoes, so to speak,” says Dr. Cameron. “I know the frustrations they deal with daily.”
Some primary care doctors seem pleased the hospitalist shares their background, Dr. Chmelik notes, but she also emphasizes that continuity of care is much more important.
Everyone agreed that, in most cases, primary care doctors are grateful hospitalists are there to take over inpatient care, but Dr. Kedansky notes that some family physicians still want to do it all. “I give those docs credit if they want to maintain care of their patients when they’re in the hospital,” he says. “But most simply can’t keep up with it.”
Improved Training
Dr. Enns says that in Canada, family physicians have training in palliative care, but internists don’t. (They do in the U.S.)
“Family physicians have training in the broader aspects of patient care,” she says. “They view patients in terms of the goal to be achieved rather than the diagnosis.” However, she feels internists have superior training in differential diagnosis.
In her view, family physicians and internists learn skills they originally lacked as they evolve as hospitalists. “I know I’ve learned a lot about diagnosis since I’ve been a hospitalist,” she confesses. She feels that both groups—internists and family physicians—would benefit as hospitalists if they had cross-training in each other’s specialties.
More training on the business side would have been helpful, suggests Dr. Chmelik. “We learned how to be doctors,” she says, “but we also need to know how to function in a hospital setting.” She mentioned billing, length-of-stay protocols, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) rules as examples. She also would have liked more training in infection control.
Family practice physicians fear the specialty has been slower than internal medicine in developing a program that would offer credentialing for hospitalists.
The U.S. family medicine hospitalists worry that because they are such a small part of the hospitalist family their position will be further eroded unless they can offer a similar credential.
Further, all cited the urgency of expanding fellowships in hospital medicine as a means of training that could lead to credentialing.
It is unlikely any sort of joint credential will be developed, given that the certifying boards of family medicine and internal medicine are individual entities, they say.
In the Minority
Being a minority in the ranks of hospitalists has its disadvantages. Some family medicine hospitalists feel they have to struggle to achieve recognition. But all agreed there is no problem with colleagues.
“I manage a mixed group of internists and family physicians,” says Dr. Kedansky, “and there is no distinction.”
Patient respect is not at issue, either. The panelists say patients are curious about the term hospitalist but seem largely oblivious to any further distinction. If there is any preference for internist hospitalists—and not everyone agrees there is—it seems to be on the part of the people who hire hospitalists.
Some potential employers specify in their employment ads that an applicant be certified in internal medicine, but Dr. Kedansky suggests that because most hospitalists are internists, many hirers assume that is the standard. “The person’s skills are what’s important, not the specialty,” he says. “If the doctor wants the job, he should persist.” But Dr. Gundersen, who thinks there is bias in some cases, says he has found that some hirers will not even interview candidates with family physician boards. “This situation limits a family physician hospitalist’s ability to move around or even get a job in the first place,” he says.
Dr. Cameron knows whereof he speaks. “I had a few hospital groups and hospitals dismiss my [resume] without even talking to me despite my experience and stellar references,” she says of her frustrating year-and-a-half search for her present position.
Family physician hospitalists may have a bigger hurdle to overcome, acknowledges Dr. Chmelik. “We may have to prove more, but it is possible to earn recognition,” she believes. Dr. Aguirre concurs: “Respect is earned and not a predetermined right.”
In Canada there is no hiring issue because almost all hospitalists are family physicians, but Dr. Enns says her U.S. colleagues should “feel their own worth more. They add great value to the skills that internists bring.”
Outlook
Fewer doctors are opting to take the family medicine boards, but leaders are rising to the challenge to redefine and reassert the importance of the needs served by family physicians. At the same time, there is increasing demand for hospitalists.
According to Dr. Aguirre, demand may double—or go even higher—within the next 10 years.
“There are not enough internal medicine physicians, family medicine physicians, pediatric physicians, and physician extenders completing training or leaving private practice to become hospitalists in the near future to fill the oncoming void,” he warns.
Even if this situation proves true and hospitalist jobs are everywhere for the taking, it’s unclear whether that will rekindle interest in family practice as a path to becoming a hospitalist. But one thing seems certain: There will be credentialing processes for family physician and internist hospitalists.
Dr. Kedansky is concerned that family medicine is playing catch-up on this issue, and he wonders what effect credentialing will have. “Now it’s on the radar screen, though,” he says.
Dr. Cameron shares his concerns. She fears that if family physicians lack equal footing with internists as hospitalists, many rural and smaller hospitals will be without hospitalist coverage.
Early on, the medical community in Canada considered that the role of family medicine hospitalist might be a temporary one, taken to give family practice medicine time to regain strength, says Dr. Enns. “Now, there are no signs that it’s temporary,” she says. “It’s an effective method of patient care, and the community has embraced it. There are no more naysayers.”
Getting new physicians interested in the specialty is key, says Dr. Chmelik.
“Fellowships for further training are important,” she says. “We need to work with medical students too, show them there are options within the field. They want choices.”
Dr. Gundersen suggests that whether one is an internist or a family-physician hospitalist may not make much difference in years to come. “I think that in the future physicians will be classified on the basis of whether they are outpatient or inpatient doctors, rather than all these other designations,” he says. “It’s getting harder and harder to be both.” TH
Joen Kinnan is a frequent contributor to The Hospitalist.
Although the vast majority of physicians who practice hospital medicine in the United States are board certified in internal medicine, about 3% of hospitalists have their certification in family medicine.
How do differences in training, general outlook on the practice of medicine, or other factors affect their roles as hospitalists? Do practitioners of family medicine bring special skills to inpatient care? Why do they choose to become hospitalists instead of community-based family doctors? Does their certification in family practice give them a particular bond with the patient’s primary care doctor who may also be a family practitioner? How do they fit into the hospitalist picture, which is—at least in the U.S.—so dominated by internists?
To find out, we asked six hospitalists certified in family medicine:
- Jasen W. Gundersen, MD, division chief of hospital medicine, University of Massachusetts Memorial Medical Center, and assistant professor, UMass. Medical School, Worcester, Mass.
- Michael Kedansky, MD, lead hospitalist at the Kino Campus of University Physicians Healthcare Hospital in Tucson, Ariz., and clinical assistant professor of family and community medicine at the University of Arizona College of Medicine;
- Elizabeth Chmelik, MD, director of the Inpatient Medical Program at Scott and White University Medical Campus at Texas A&M University in Austin;
- Echo-Marie Enns, MD, a family practice hospitalist at the Peter Lougheed Center in Calgary, Alberta, Canada.
- Felix Aguirre, MD, vice president of medical affairs at IPC-the Hospitalist Company, San Antonio, Texas; and
- Jennifer Cameron, MD, a family medicine hospitalist with Central Texas Hospitalist who practices at St. David’s Hospital, Round Rock, Texas.
Drs. Gundersen, Kedansky, and Chmelik are members of SHM’s Family Practice Task Force.
Training And Decisions
Most of the experts we spoke with agree training influenced their decision to become hospitalists. They cite the diversity of cases in family practice residency (adult, pediatric, and obstetric/gynecologic), which they felt they would also find in hospital medicine.
Dr. Gundersen, chair of SHM’s Family Practice Task Force, suspects internists and family physicians probably share one motivator for opting into hospital medicine: the hospital environment. “Even in residency, I liked my time in the hospital,” Dr. Gundersen says. Echoing that sentiment, Dr. Kedansky says he missed hospital work when he was in community practice.
Family medicine is about people and relationships, says Dr. Chmelik. “You can get that same satisfaction on an inpatient basis,” she says. “I’ve always liked seeing the same patients from day to day. You get instant gratification.”
The higher levels of support and resources available in a hospital environment as opposed to those in a community-based practice appeal to Dr. Enns.
Dr. Gundersen adds that some physicians don’t like all the paperwork office practice entails; others favor the regulated hours of hospital practice. “People often evolve into it as they get more experience,” he says. “They feel that hospital medicine gives them a chance to really make a difference.”
Dr. Cameron agrees about the paperwork. “Out of residency, I became a primary care physician in Tucson,” she says. “When the local hospital group became unexpectedly short-handed, they asked me to fill in on weekends. Once I proved myself with my eagerness and team spirit, they asked me to join their group. The timing was just right: the office management, billings, paperwork, employee issues, and 24/7 schedule were just killing me, and I was ready to try something else.”
Dr. Aguirre says his hospitalist career grew out of his work with a primary care group. His primary aim was standardizing the care of the hospitalized patients in the group.
Whole-Patient View
What special skills do family medicine physicians bring to hospital medicine? The experts quickly pointed out that though training and backgrounds might differ somewhat between internists and family medicine hospitalists they view their respective skills as complementary.
“Family medicine physicians bring a wider breadth of general knowledge in more medical areas than a traditional internal medicine physician, but an internal medicine physician is expected to have a greater depth of knowledge in general adult medicine, which is the current mainstay of hospital medicine,” says Dr. Aguirre. But he suggests that the knowledge base tends to equalize with experience as internal medicine (IM) and family medicine hospitalists cover each other.
However, he also believes a family physician initially brings more knowledge and practical experience in gynecology, behavioral science, pediatric, orthopedic, and family medicine. “These experiences can be especially useful when crafting hospitalist programs to serve these specific target audiences and to help staff pediatric or IM/pediatric hospitalist programs as well,” he says.
Family medicine covers a lot of bases, these experts say. “Family medicine hospitalists have training in family dynamics, end-of-life issues, and family counseling,” says Dr. Chmelik. “These skills frequently come into play with hospitalized patients.” For Dr. Kedansky, family medicine residency training focuses on treating the whole patient “from birth to death.”
Dr. Gundersen knows how broad that role is. “We have the ability to treat adult, newborn, pediatric, and obstetric/gynecologic patients,” he says. “Some family medicine hospitalists even do labor management,” he says.
According to him, a family practice hospitalist gives a hospital special value because one hospitalist can take care of children as well as adults.
Community is important in the hospitalist-patient relationship. “Family practitioners learn how patients fit into the community,” says Dr. Enns. “We can picture patients in a home setting. This helps us in getting patients ready for discharge.”
The outpatient perspective gives family practitioners more foresight, says Dr. Cameron. Family practitioners “see possible roadblocks to a successful discharge to the home and are more willing to jump through the necessary hoops to ensure things go as planned once the patient is discharged,” she says. “As prior outpatient physicians, we know the frustration of having a patient just discharged from the hospital land in our clinic Monday morning with many issues unaddressed.”
Many family physicians had office practices before becoming hospitalists. “We understand how the continuum works,” says Dr. Kedansky.
—Elizabeth Chmelik, MD, director of the Inpatient Medical Program at Scott and White University Medical Campus at Texas A&M University, Austin
Bond with Primary Docs
Does belonging to the same “fraternity”—family medicine—create a special relationship between a primary care doctor and a hospitalist with a similar background and training?
From the Canadian perspective, Dr. Enns thinks it may. She says resource constraints may apply to the primary care physician working in the community. “When I am treating a patient, I sometimes find a condition that is unrelated to the patient’s hospitalization,” she says. “I have better access to resources, so I might be able to accomplish a lot for my colleague. I’ll call and ask if the doctor would like me to run an appropriate test, for example. Usually the primary care doctor is extremely grateful for the help.”
In the U.S., Dr. Gundersen suggests that the specialty of neither the primary care doctor nor the hospitalist is particularly important. “Continuity of care is the critical thing,” he says. “The point is to have good communication and a smooth handoff back to the primary care doctor.”
Dr. Kedansky agrees on the necessity for good communication but feels a greater sense of connectivity with the primary care physician, partly because he has been one. “I also know many of the docs personally, so that helps,” he says.
For Drs. Aguirre and Cameron, having worked as a primary care physician helps them empathize with their concerns about continuity and quality of care.
“I have been in their shoes, so to speak,” says Dr. Cameron. “I know the frustrations they deal with daily.”
Some primary care doctors seem pleased the hospitalist shares their background, Dr. Chmelik notes, but she also emphasizes that continuity of care is much more important.
Everyone agreed that, in most cases, primary care doctors are grateful hospitalists are there to take over inpatient care, but Dr. Kedansky notes that some family physicians still want to do it all. “I give those docs credit if they want to maintain care of their patients when they’re in the hospital,” he says. “But most simply can’t keep up with it.”
Improved Training
Dr. Enns says that in Canada, family physicians have training in palliative care, but internists don’t. (They do in the U.S.)
“Family physicians have training in the broader aspects of patient care,” she says. “They view patients in terms of the goal to be achieved rather than the diagnosis.” However, she feels internists have superior training in differential diagnosis.
In her view, family physicians and internists learn skills they originally lacked as they evolve as hospitalists. “I know I’ve learned a lot about diagnosis since I’ve been a hospitalist,” she confesses. She feels that both groups—internists and family physicians—would benefit as hospitalists if they had cross-training in each other’s specialties.
More training on the business side would have been helpful, suggests Dr. Chmelik. “We learned how to be doctors,” she says, “but we also need to know how to function in a hospital setting.” She mentioned billing, length-of-stay protocols, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) rules as examples. She also would have liked more training in infection control.
Family practice physicians fear the specialty has been slower than internal medicine in developing a program that would offer credentialing for hospitalists.
The U.S. family medicine hospitalists worry that because they are such a small part of the hospitalist family their position will be further eroded unless they can offer a similar credential.
Further, all cited the urgency of expanding fellowships in hospital medicine as a means of training that could lead to credentialing.
It is unlikely any sort of joint credential will be developed, given that the certifying boards of family medicine and internal medicine are individual entities, they say.
In the Minority
Being a minority in the ranks of hospitalists has its disadvantages. Some family medicine hospitalists feel they have to struggle to achieve recognition. But all agreed there is no problem with colleagues.
“I manage a mixed group of internists and family physicians,” says Dr. Kedansky, “and there is no distinction.”
Patient respect is not at issue, either. The panelists say patients are curious about the term hospitalist but seem largely oblivious to any further distinction. If there is any preference for internist hospitalists—and not everyone agrees there is—it seems to be on the part of the people who hire hospitalists.
Some potential employers specify in their employment ads that an applicant be certified in internal medicine, but Dr. Kedansky suggests that because most hospitalists are internists, many hirers assume that is the standard. “The person’s skills are what’s important, not the specialty,” he says. “If the doctor wants the job, he should persist.” But Dr. Gundersen, who thinks there is bias in some cases, says he has found that some hirers will not even interview candidates with family physician boards. “This situation limits a family physician hospitalist’s ability to move around or even get a job in the first place,” he says.
Dr. Cameron knows whereof he speaks. “I had a few hospital groups and hospitals dismiss my [resume] without even talking to me despite my experience and stellar references,” she says of her frustrating year-and-a-half search for her present position.
Family physician hospitalists may have a bigger hurdle to overcome, acknowledges Dr. Chmelik. “We may have to prove more, but it is possible to earn recognition,” she believes. Dr. Aguirre concurs: “Respect is earned and not a predetermined right.”
In Canada there is no hiring issue because almost all hospitalists are family physicians, but Dr. Enns says her U.S. colleagues should “feel their own worth more. They add great value to the skills that internists bring.”
Outlook
Fewer doctors are opting to take the family medicine boards, but leaders are rising to the challenge to redefine and reassert the importance of the needs served by family physicians. At the same time, there is increasing demand for hospitalists.
According to Dr. Aguirre, demand may double—or go even higher—within the next 10 years.
“There are not enough internal medicine physicians, family medicine physicians, pediatric physicians, and physician extenders completing training or leaving private practice to become hospitalists in the near future to fill the oncoming void,” he warns.
Even if this situation proves true and hospitalist jobs are everywhere for the taking, it’s unclear whether that will rekindle interest in family practice as a path to becoming a hospitalist. But one thing seems certain: There will be credentialing processes for family physician and internist hospitalists.
Dr. Kedansky is concerned that family medicine is playing catch-up on this issue, and he wonders what effect credentialing will have. “Now it’s on the radar screen, though,” he says.
Dr. Cameron shares his concerns. She fears that if family physicians lack equal footing with internists as hospitalists, many rural and smaller hospitals will be without hospitalist coverage.
Early on, the medical community in Canada considered that the role of family medicine hospitalist might be a temporary one, taken to give family practice medicine time to regain strength, says Dr. Enns. “Now, there are no signs that it’s temporary,” she says. “It’s an effective method of patient care, and the community has embraced it. There are no more naysayers.”
Getting new physicians interested in the specialty is key, says Dr. Chmelik.
“Fellowships for further training are important,” she says. “We need to work with medical students too, show them there are options within the field. They want choices.”
Dr. Gundersen suggests that whether one is an internist or a family-physician hospitalist may not make much difference in years to come. “I think that in the future physicians will be classified on the basis of whether they are outpatient or inpatient doctors, rather than all these other designations,” he says. “It’s getting harder and harder to be both.” TH
Joen Kinnan is a frequent contributor to The Hospitalist.
Although the vast majority of physicians who practice hospital medicine in the United States are board certified in internal medicine, about 3% of hospitalists have their certification in family medicine.
How do differences in training, general outlook on the practice of medicine, or other factors affect their roles as hospitalists? Do practitioners of family medicine bring special skills to inpatient care? Why do they choose to become hospitalists instead of community-based family doctors? Does their certification in family practice give them a particular bond with the patient’s primary care doctor who may also be a family practitioner? How do they fit into the hospitalist picture, which is—at least in the U.S.—so dominated by internists?
To find out, we asked six hospitalists certified in family medicine:
- Jasen W. Gundersen, MD, division chief of hospital medicine, University of Massachusetts Memorial Medical Center, and assistant professor, UMass. Medical School, Worcester, Mass.
- Michael Kedansky, MD, lead hospitalist at the Kino Campus of University Physicians Healthcare Hospital in Tucson, Ariz., and clinical assistant professor of family and community medicine at the University of Arizona College of Medicine;
- Elizabeth Chmelik, MD, director of the Inpatient Medical Program at Scott and White University Medical Campus at Texas A&M University in Austin;
- Echo-Marie Enns, MD, a family practice hospitalist at the Peter Lougheed Center in Calgary, Alberta, Canada.
- Felix Aguirre, MD, vice president of medical affairs at IPC-the Hospitalist Company, San Antonio, Texas; and
- Jennifer Cameron, MD, a family medicine hospitalist with Central Texas Hospitalist who practices at St. David’s Hospital, Round Rock, Texas.
Drs. Gundersen, Kedansky, and Chmelik are members of SHM’s Family Practice Task Force.
Training And Decisions
Most of the experts we spoke with agree training influenced their decision to become hospitalists. They cite the diversity of cases in family practice residency (adult, pediatric, and obstetric/gynecologic), which they felt they would also find in hospital medicine.
Dr. Gundersen, chair of SHM’s Family Practice Task Force, suspects internists and family physicians probably share one motivator for opting into hospital medicine: the hospital environment. “Even in residency, I liked my time in the hospital,” Dr. Gundersen says. Echoing that sentiment, Dr. Kedansky says he missed hospital work when he was in community practice.
Family medicine is about people and relationships, says Dr. Chmelik. “You can get that same satisfaction on an inpatient basis,” she says. “I’ve always liked seeing the same patients from day to day. You get instant gratification.”
The higher levels of support and resources available in a hospital environment as opposed to those in a community-based practice appeal to Dr. Enns.
Dr. Gundersen adds that some physicians don’t like all the paperwork office practice entails; others favor the regulated hours of hospital practice. “People often evolve into it as they get more experience,” he says. “They feel that hospital medicine gives them a chance to really make a difference.”
Dr. Cameron agrees about the paperwork. “Out of residency, I became a primary care physician in Tucson,” she says. “When the local hospital group became unexpectedly short-handed, they asked me to fill in on weekends. Once I proved myself with my eagerness and team spirit, they asked me to join their group. The timing was just right: the office management, billings, paperwork, employee issues, and 24/7 schedule were just killing me, and I was ready to try something else.”
Dr. Aguirre says his hospitalist career grew out of his work with a primary care group. His primary aim was standardizing the care of the hospitalized patients in the group.
Whole-Patient View
What special skills do family medicine physicians bring to hospital medicine? The experts quickly pointed out that though training and backgrounds might differ somewhat between internists and family medicine hospitalists they view their respective skills as complementary.
“Family medicine physicians bring a wider breadth of general knowledge in more medical areas than a traditional internal medicine physician, but an internal medicine physician is expected to have a greater depth of knowledge in general adult medicine, which is the current mainstay of hospital medicine,” says Dr. Aguirre. But he suggests that the knowledge base tends to equalize with experience as internal medicine (IM) and family medicine hospitalists cover each other.
However, he also believes a family physician initially brings more knowledge and practical experience in gynecology, behavioral science, pediatric, orthopedic, and family medicine. “These experiences can be especially useful when crafting hospitalist programs to serve these specific target audiences and to help staff pediatric or IM/pediatric hospitalist programs as well,” he says.
Family medicine covers a lot of bases, these experts say. “Family medicine hospitalists have training in family dynamics, end-of-life issues, and family counseling,” says Dr. Chmelik. “These skills frequently come into play with hospitalized patients.” For Dr. Kedansky, family medicine residency training focuses on treating the whole patient “from birth to death.”
Dr. Gundersen knows how broad that role is. “We have the ability to treat adult, newborn, pediatric, and obstetric/gynecologic patients,” he says. “Some family medicine hospitalists even do labor management,” he says.
According to him, a family practice hospitalist gives a hospital special value because one hospitalist can take care of children as well as adults.
Community is important in the hospitalist-patient relationship. “Family practitioners learn how patients fit into the community,” says Dr. Enns. “We can picture patients in a home setting. This helps us in getting patients ready for discharge.”
The outpatient perspective gives family practitioners more foresight, says Dr. Cameron. Family practitioners “see possible roadblocks to a successful discharge to the home and are more willing to jump through the necessary hoops to ensure things go as planned once the patient is discharged,” she says. “As prior outpatient physicians, we know the frustration of having a patient just discharged from the hospital land in our clinic Monday morning with many issues unaddressed.”
Many family physicians had office practices before becoming hospitalists. “We understand how the continuum works,” says Dr. Kedansky.
—Elizabeth Chmelik, MD, director of the Inpatient Medical Program at Scott and White University Medical Campus at Texas A&M University, Austin
Bond with Primary Docs
Does belonging to the same “fraternity”—family medicine—create a special relationship between a primary care doctor and a hospitalist with a similar background and training?
From the Canadian perspective, Dr. Enns thinks it may. She says resource constraints may apply to the primary care physician working in the community. “When I am treating a patient, I sometimes find a condition that is unrelated to the patient’s hospitalization,” she says. “I have better access to resources, so I might be able to accomplish a lot for my colleague. I’ll call and ask if the doctor would like me to run an appropriate test, for example. Usually the primary care doctor is extremely grateful for the help.”
In the U.S., Dr. Gundersen suggests that the specialty of neither the primary care doctor nor the hospitalist is particularly important. “Continuity of care is the critical thing,” he says. “The point is to have good communication and a smooth handoff back to the primary care doctor.”
Dr. Kedansky agrees on the necessity for good communication but feels a greater sense of connectivity with the primary care physician, partly because he has been one. “I also know many of the docs personally, so that helps,” he says.
For Drs. Aguirre and Cameron, having worked as a primary care physician helps them empathize with their concerns about continuity and quality of care.
“I have been in their shoes, so to speak,” says Dr. Cameron. “I know the frustrations they deal with daily.”
Some primary care doctors seem pleased the hospitalist shares their background, Dr. Chmelik notes, but she also emphasizes that continuity of care is much more important.
Everyone agreed that, in most cases, primary care doctors are grateful hospitalists are there to take over inpatient care, but Dr. Kedansky notes that some family physicians still want to do it all. “I give those docs credit if they want to maintain care of their patients when they’re in the hospital,” he says. “But most simply can’t keep up with it.”
Improved Training
Dr. Enns says that in Canada, family physicians have training in palliative care, but internists don’t. (They do in the U.S.)
“Family physicians have training in the broader aspects of patient care,” she says. “They view patients in terms of the goal to be achieved rather than the diagnosis.” However, she feels internists have superior training in differential diagnosis.
In her view, family physicians and internists learn skills they originally lacked as they evolve as hospitalists. “I know I’ve learned a lot about diagnosis since I’ve been a hospitalist,” she confesses. She feels that both groups—internists and family physicians—would benefit as hospitalists if they had cross-training in each other’s specialties.
More training on the business side would have been helpful, suggests Dr. Chmelik. “We learned how to be doctors,” she says, “but we also need to know how to function in a hospital setting.” She mentioned billing, length-of-stay protocols, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) rules as examples. She also would have liked more training in infection control.
Family practice physicians fear the specialty has been slower than internal medicine in developing a program that would offer credentialing for hospitalists.
The U.S. family medicine hospitalists worry that because they are such a small part of the hospitalist family their position will be further eroded unless they can offer a similar credential.
Further, all cited the urgency of expanding fellowships in hospital medicine as a means of training that could lead to credentialing.
It is unlikely any sort of joint credential will be developed, given that the certifying boards of family medicine and internal medicine are individual entities, they say.
In the Minority
Being a minority in the ranks of hospitalists has its disadvantages. Some family medicine hospitalists feel they have to struggle to achieve recognition. But all agreed there is no problem with colleagues.
“I manage a mixed group of internists and family physicians,” says Dr. Kedansky, “and there is no distinction.”
Patient respect is not at issue, either. The panelists say patients are curious about the term hospitalist but seem largely oblivious to any further distinction. If there is any preference for internist hospitalists—and not everyone agrees there is—it seems to be on the part of the people who hire hospitalists.
Some potential employers specify in their employment ads that an applicant be certified in internal medicine, but Dr. Kedansky suggests that because most hospitalists are internists, many hirers assume that is the standard. “The person’s skills are what’s important, not the specialty,” he says. “If the doctor wants the job, he should persist.” But Dr. Gundersen, who thinks there is bias in some cases, says he has found that some hirers will not even interview candidates with family physician boards. “This situation limits a family physician hospitalist’s ability to move around or even get a job in the first place,” he says.
Dr. Cameron knows whereof he speaks. “I had a few hospital groups and hospitals dismiss my [resume] without even talking to me despite my experience and stellar references,” she says of her frustrating year-and-a-half search for her present position.
Family physician hospitalists may have a bigger hurdle to overcome, acknowledges Dr. Chmelik. “We may have to prove more, but it is possible to earn recognition,” she believes. Dr. Aguirre concurs: “Respect is earned and not a predetermined right.”
In Canada there is no hiring issue because almost all hospitalists are family physicians, but Dr. Enns says her U.S. colleagues should “feel their own worth more. They add great value to the skills that internists bring.”
Outlook
Fewer doctors are opting to take the family medicine boards, but leaders are rising to the challenge to redefine and reassert the importance of the needs served by family physicians. At the same time, there is increasing demand for hospitalists.
According to Dr. Aguirre, demand may double—or go even higher—within the next 10 years.
“There are not enough internal medicine physicians, family medicine physicians, pediatric physicians, and physician extenders completing training or leaving private practice to become hospitalists in the near future to fill the oncoming void,” he warns.
Even if this situation proves true and hospitalist jobs are everywhere for the taking, it’s unclear whether that will rekindle interest in family practice as a path to becoming a hospitalist. But one thing seems certain: There will be credentialing processes for family physician and internist hospitalists.
Dr. Kedansky is concerned that family medicine is playing catch-up on this issue, and he wonders what effect credentialing will have. “Now it’s on the radar screen, though,” he says.
Dr. Cameron shares his concerns. She fears that if family physicians lack equal footing with internists as hospitalists, many rural and smaller hospitals will be without hospitalist coverage.
Early on, the medical community in Canada considered that the role of family medicine hospitalist might be a temporary one, taken to give family practice medicine time to regain strength, says Dr. Enns. “Now, there are no signs that it’s temporary,” she says. “It’s an effective method of patient care, and the community has embraced it. There are no more naysayers.”
Getting new physicians interested in the specialty is key, says Dr. Chmelik.
“Fellowships for further training are important,” she says. “We need to work with medical students too, show them there are options within the field. They want choices.”
Dr. Gundersen suggests that whether one is an internist or a family-physician hospitalist may not make much difference in years to come. “I think that in the future physicians will be classified on the basis of whether they are outpatient or inpatient doctors, rather than all these other designations,” he says. “It’s getting harder and harder to be both.” TH
Joen Kinnan is a frequent contributor to The Hospitalist.
The New Institutional Leadership
Dr. Z has practiced hospital medicine at his local community hospital for the past three years. When he came on staff he quickly volunteered for a committee, and today he is its chair. Though he has a heavy workload, he has found the time to take several business courses at a nearby college, and he rarely turns down an opportunity to address a group.
Since he began his practice, he has never missed a local or national meeting of the professional associations to which he belongs. Dr. Z is a hospitalist with an ardent desire to make a difference. He believes he can be most effective in a hospital-wide administrative position, and he is preparing himself.
Dr. Z is a hypothetical example of a growing number of practicing hospitalists who are moving—or desire to move—into hospital-wide decision-making positions. What is the likelihood for their advancement to the higher echelons of hospital administration? Very good for those who have the right stuff for leadership, according to Larry Wellikson, MD, CEO of SHM.
Consider this: Just a decade ago, there were about 100 pioneering hospitalists caring for patients in 20 hospitals. Today there are 20,000 hospitalists serving patients in 2,500 hospitals across the country. Hospital medicine is the fastest growing medical specialty in the United States. The time is right for hospitalists to rise to the fore—not just as leaders of their hospitalist groups but also as system-wide decision makers.
Stacy Goldsholl, MD, represents the new breed: hospitalist as leader. Dr. Goldsholl has been a hospitalist for 12 years. “I got my first job as a community hospitalist before the term was even coined,” she says. “After about five years, I really hit a low point in my career. I was dissatisfied with the way the system was working; I didn’t feel there was enough emphasis on quality patient care. I was at a crossroad. I even considered giving up medicine altogether and going to rabbinical school,” she says, laughing. “But I was very passionate about making things better, so instead of quitting medicine, I embarked on a solo jaunt around the country trying to interest people in improving hospital medicine.”
Today Dr. Goldsholl is president of the Hospital Medicine Division of TeamHealth (Knoxville, Tenn.), a nationwide outsourcing provider of hospitalists in areas as far flung as Puerto Rico and Hawaii.
Though there are no hard-and-fast statistics on how many hospitalists now have leadership roles, Dr. Wellikson says the numbers are swelling. “It’s getting harder and harder to find someone who has strong leadership skills who’s five years into practice who is still just seeing patients,” he says. “There’s such a crying need for leadership in managing the team, leading the hospital medicine group, improving the hospital, improving the quality of care … there’s an enormous void. The first time somebody shows up who has an interest or an aptitude, someone will say, ‘Why don’t you be in charge?’ ”
What Hospitalists Bring to the Leadership Table
Study after study indicates hospitals employing hospitalists experience an improvement in the bottom line that is due, in part, to greater efficiency. This is an important consideration in the current economic crunch in which many hospitals find themselves, but today there is an increased focus on improving patient care as well.
In both efficiency and patient care, hospitalists are uniquely positioned to bring something to the leadership table that other candidates might not. “Hospitalists have a holistic view of the hospital,” says Dr. Goldsholl. “Private physicians don’t have the same connectedness to all the parts. That kind of experience is very valuable. After all, that’s what the hospital is all about.”
Jack M. Percelay, MD, a member of SHM’s Board of Directors, puts it another way. “Clearly, administrative positions require some knowledge of hospital function,” he says. “On-site physicians are certainly more aware of where the problems are. They face them on a daily basis.”
Dr. Wellikson adds, “From the very beginning of their medical careers, even when their main role is seeing patients, hospitalists are looking at the hospital as a system as an institution. They may be members of a quality-improvement team or a group that looks at the flow of patients from the emergency room to the hospital. It becomes sort of second nature to them. Our doctors learn these competencies from the beginning. In their training and their involvement with SHM, whole sections are devoted to systems improvement, leadership, and things like that.”
Dr. Wellikson suggests a demographic reason so many hospitalists look forward to climbing the administrative ladder: “It’s the times. Older doctors may be counting the days till retirement, whereas most hospitalists are younger—the average age is 37—and they say, ‘Hey, I’m going to have 20 more years of this. If I don’t change things, who will?’
“I’ll give you an analogy. When you go to a hotel and your towels aren’t delivered, you might complain until you get them, but you don’t try to manage the hotel. That’s the way practicing doctors felt 20 years ago. But hospitalists, because they’re going to go to work every day in that hospital, if it’s not working tip-top, they’re going to get involved. It’s an evolution in healthcare.”
How to Become a Hospitalist Leader
We asked our experts what advice they would give hospitalists who aspire to critical decision-making positions. “Even if you have natural skills as a leader—you’re charismatic, you take on responsibility—leadership is a skill like any other,” says Dr. Wellikson. “Take the time early in your career to develop that skill. Get involved in some project you feel passionate about. Part of leadership is getting other people to move in the right direction and part is dealing with the people who won’t follow. That can be frustrating. See how this feels to you. Get the education you need, and don’t be afraid to fail. Everybody has failures.”
Dr. Percelay suggests finding activities in your group where you can take initiative. “Clinical legitimacy is key, too, together with a systems viewpoint,” he says. “I would also recommend CME [continuing medical education]-type activities to develop leadership skills. There are the [SHM] Leadership Academy, local business schools, and the American College of Physician Executives, but learn mostly by doing and participating. Joining national organizations is also helpful because you will interact with other like-minded individuals.”
Dr. Goldsholl advises hospitalists to be passionate about their beliefs and to have confidence in what they do. She remembers a seminar she attended at which the speaker—a prominent business executive—gave this advice: “If you’ve never been fired, you are afraid to stand up for what you believe.”
Decision-making positions require hard work and long hours, Dr. Goldsholl cautions. “You have to keep a balance between your personal life and your career. And never underestimate the power of networking at regional and national levels as well as locally. Make your voice heard in print and [at] speaking engagements too. Get published in the Journal of Hospital Medicine. People do read these articles.”
Trends for Hospitalists as Decision Makers
Everyone with whom we spoke predicts a bright future for hospitalists who want to become critical decision makers. “Hospitalists understand the important manifestations of the way all pieces fit together to impact even a single event,” says Dr. Goldsholl. “Already hospitalists are vice presidents of medical affairs, chief operating officers, and so forth. This trend toward placing hospitalists in management roles is being driven, in large part, by the institutional knowledge that hospitalists have. I expect the trend will only expand.”
“There is so much overlap in medicine that what I see developing is a spirit of collaboration,” says Dr. Percelay. “What’s good for the hospitalist is good for the hospital and ultimately good for the patient. I believe that an alignment of incentives is driving the trend toward the appointment of hospitalists to general leadership positions.”
Hospitalists can create a healthcare system driven by teams of healthcare professionals and based on delivering measurable quality, according to Dr. Wellikson, who says hospitalists will play a major role in leading the quality revolution in this country. “We are moving to a time when business and Medicare are driving toward pay for performance,” he says. “Not just, ‘Did you do the surgery?’ but, ‘How well did you do the surgery?’ ”
Most importantly, Dr. Wellikson believes hospitalists are positioned incredibly well to be leaders in this movement. “The first thing people have to do is agree there is a problem. Then they have to measure the performance, try to improve the situation, and then measure the performance again. This is the wave of the future. We [hospitalists] are working with the government, with the National Quality Forum, with the Institute for Healthcare Improvement. Improvement in quality of care is the number one trend upon which hospitalist leaders will have an impact.”
Another emerging trend: Hospitalist decision makers will influence a redesigned hospital of the future. (Dr. Wellikson is one of 20 people on the Joint Commission Hospital of the Future Work Group.) “The hospital of the future will be very different,” explains Dr. Wellikson. “There’s going to be a home team in the new hospital. It will consist of the ED doctors, critical-care doctors, and hospitalists, working with nurses, pharmacists, and the administration as a team to deliver more technology and do more for sicker people.”
These efforts will be on a collision course with the hospital’s ability to afford them, he believes, so hospitalist leadership will be key to creating an efficient hospital that uses its resources in the best way possible and works as a team.
As more and more hospitalists gravitate toward hospitalwide leadership positions, they will confront some of their own. “It’s going to be very interesting,” says Dr. Percelay, “when the hospital medicine group leader differs with the vice president of medical affairs and they both share the same background. The hospital medicine group leader will no longer be able to say, ‘You don’t know where I’m coming from.’ ” TH
Joen Kinnan is a medical journalist based in Chicago.
Dr. Z has practiced hospital medicine at his local community hospital for the past three years. When he came on staff he quickly volunteered for a committee, and today he is its chair. Though he has a heavy workload, he has found the time to take several business courses at a nearby college, and he rarely turns down an opportunity to address a group.
Since he began his practice, he has never missed a local or national meeting of the professional associations to which he belongs. Dr. Z is a hospitalist with an ardent desire to make a difference. He believes he can be most effective in a hospital-wide administrative position, and he is preparing himself.
Dr. Z is a hypothetical example of a growing number of practicing hospitalists who are moving—or desire to move—into hospital-wide decision-making positions. What is the likelihood for their advancement to the higher echelons of hospital administration? Very good for those who have the right stuff for leadership, according to Larry Wellikson, MD, CEO of SHM.
Consider this: Just a decade ago, there were about 100 pioneering hospitalists caring for patients in 20 hospitals. Today there are 20,000 hospitalists serving patients in 2,500 hospitals across the country. Hospital medicine is the fastest growing medical specialty in the United States. The time is right for hospitalists to rise to the fore—not just as leaders of their hospitalist groups but also as system-wide decision makers.
Stacy Goldsholl, MD, represents the new breed: hospitalist as leader. Dr. Goldsholl has been a hospitalist for 12 years. “I got my first job as a community hospitalist before the term was even coined,” she says. “After about five years, I really hit a low point in my career. I was dissatisfied with the way the system was working; I didn’t feel there was enough emphasis on quality patient care. I was at a crossroad. I even considered giving up medicine altogether and going to rabbinical school,” she says, laughing. “But I was very passionate about making things better, so instead of quitting medicine, I embarked on a solo jaunt around the country trying to interest people in improving hospital medicine.”
Today Dr. Goldsholl is president of the Hospital Medicine Division of TeamHealth (Knoxville, Tenn.), a nationwide outsourcing provider of hospitalists in areas as far flung as Puerto Rico and Hawaii.
Though there are no hard-and-fast statistics on how many hospitalists now have leadership roles, Dr. Wellikson says the numbers are swelling. “It’s getting harder and harder to find someone who has strong leadership skills who’s five years into practice who is still just seeing patients,” he says. “There’s such a crying need for leadership in managing the team, leading the hospital medicine group, improving the hospital, improving the quality of care … there’s an enormous void. The first time somebody shows up who has an interest or an aptitude, someone will say, ‘Why don’t you be in charge?’ ”
What Hospitalists Bring to the Leadership Table
Study after study indicates hospitals employing hospitalists experience an improvement in the bottom line that is due, in part, to greater efficiency. This is an important consideration in the current economic crunch in which many hospitals find themselves, but today there is an increased focus on improving patient care as well.
In both efficiency and patient care, hospitalists are uniquely positioned to bring something to the leadership table that other candidates might not. “Hospitalists have a holistic view of the hospital,” says Dr. Goldsholl. “Private physicians don’t have the same connectedness to all the parts. That kind of experience is very valuable. After all, that’s what the hospital is all about.”
Jack M. Percelay, MD, a member of SHM’s Board of Directors, puts it another way. “Clearly, administrative positions require some knowledge of hospital function,” he says. “On-site physicians are certainly more aware of where the problems are. They face them on a daily basis.”
Dr. Wellikson adds, “From the very beginning of their medical careers, even when their main role is seeing patients, hospitalists are looking at the hospital as a system as an institution. They may be members of a quality-improvement team or a group that looks at the flow of patients from the emergency room to the hospital. It becomes sort of second nature to them. Our doctors learn these competencies from the beginning. In their training and their involvement with SHM, whole sections are devoted to systems improvement, leadership, and things like that.”
Dr. Wellikson suggests a demographic reason so many hospitalists look forward to climbing the administrative ladder: “It’s the times. Older doctors may be counting the days till retirement, whereas most hospitalists are younger—the average age is 37—and they say, ‘Hey, I’m going to have 20 more years of this. If I don’t change things, who will?’
“I’ll give you an analogy. When you go to a hotel and your towels aren’t delivered, you might complain until you get them, but you don’t try to manage the hotel. That’s the way practicing doctors felt 20 years ago. But hospitalists, because they’re going to go to work every day in that hospital, if it’s not working tip-top, they’re going to get involved. It’s an evolution in healthcare.”
How to Become a Hospitalist Leader
We asked our experts what advice they would give hospitalists who aspire to critical decision-making positions. “Even if you have natural skills as a leader—you’re charismatic, you take on responsibility—leadership is a skill like any other,” says Dr. Wellikson. “Take the time early in your career to develop that skill. Get involved in some project you feel passionate about. Part of leadership is getting other people to move in the right direction and part is dealing with the people who won’t follow. That can be frustrating. See how this feels to you. Get the education you need, and don’t be afraid to fail. Everybody has failures.”
Dr. Percelay suggests finding activities in your group where you can take initiative. “Clinical legitimacy is key, too, together with a systems viewpoint,” he says. “I would also recommend CME [continuing medical education]-type activities to develop leadership skills. There are the [SHM] Leadership Academy, local business schools, and the American College of Physician Executives, but learn mostly by doing and participating. Joining national organizations is also helpful because you will interact with other like-minded individuals.”
Dr. Goldsholl advises hospitalists to be passionate about their beliefs and to have confidence in what they do. She remembers a seminar she attended at which the speaker—a prominent business executive—gave this advice: “If you’ve never been fired, you are afraid to stand up for what you believe.”
Decision-making positions require hard work and long hours, Dr. Goldsholl cautions. “You have to keep a balance between your personal life and your career. And never underestimate the power of networking at regional and national levels as well as locally. Make your voice heard in print and [at] speaking engagements too. Get published in the Journal of Hospital Medicine. People do read these articles.”
Trends for Hospitalists as Decision Makers
Everyone with whom we spoke predicts a bright future for hospitalists who want to become critical decision makers. “Hospitalists understand the important manifestations of the way all pieces fit together to impact even a single event,” says Dr. Goldsholl. “Already hospitalists are vice presidents of medical affairs, chief operating officers, and so forth. This trend toward placing hospitalists in management roles is being driven, in large part, by the institutional knowledge that hospitalists have. I expect the trend will only expand.”
“There is so much overlap in medicine that what I see developing is a spirit of collaboration,” says Dr. Percelay. “What’s good for the hospitalist is good for the hospital and ultimately good for the patient. I believe that an alignment of incentives is driving the trend toward the appointment of hospitalists to general leadership positions.”
Hospitalists can create a healthcare system driven by teams of healthcare professionals and based on delivering measurable quality, according to Dr. Wellikson, who says hospitalists will play a major role in leading the quality revolution in this country. “We are moving to a time when business and Medicare are driving toward pay for performance,” he says. “Not just, ‘Did you do the surgery?’ but, ‘How well did you do the surgery?’ ”
Most importantly, Dr. Wellikson believes hospitalists are positioned incredibly well to be leaders in this movement. “The first thing people have to do is agree there is a problem. Then they have to measure the performance, try to improve the situation, and then measure the performance again. This is the wave of the future. We [hospitalists] are working with the government, with the National Quality Forum, with the Institute for Healthcare Improvement. Improvement in quality of care is the number one trend upon which hospitalist leaders will have an impact.”
Another emerging trend: Hospitalist decision makers will influence a redesigned hospital of the future. (Dr. Wellikson is one of 20 people on the Joint Commission Hospital of the Future Work Group.) “The hospital of the future will be very different,” explains Dr. Wellikson. “There’s going to be a home team in the new hospital. It will consist of the ED doctors, critical-care doctors, and hospitalists, working with nurses, pharmacists, and the administration as a team to deliver more technology and do more for sicker people.”
These efforts will be on a collision course with the hospital’s ability to afford them, he believes, so hospitalist leadership will be key to creating an efficient hospital that uses its resources in the best way possible and works as a team.
As more and more hospitalists gravitate toward hospitalwide leadership positions, they will confront some of their own. “It’s going to be very interesting,” says Dr. Percelay, “when the hospital medicine group leader differs with the vice president of medical affairs and they both share the same background. The hospital medicine group leader will no longer be able to say, ‘You don’t know where I’m coming from.’ ” TH
Joen Kinnan is a medical journalist based in Chicago.
Dr. Z has practiced hospital medicine at his local community hospital for the past three years. When he came on staff he quickly volunteered for a committee, and today he is its chair. Though he has a heavy workload, he has found the time to take several business courses at a nearby college, and he rarely turns down an opportunity to address a group.
Since he began his practice, he has never missed a local or national meeting of the professional associations to which he belongs. Dr. Z is a hospitalist with an ardent desire to make a difference. He believes he can be most effective in a hospital-wide administrative position, and he is preparing himself.
Dr. Z is a hypothetical example of a growing number of practicing hospitalists who are moving—or desire to move—into hospital-wide decision-making positions. What is the likelihood for their advancement to the higher echelons of hospital administration? Very good for those who have the right stuff for leadership, according to Larry Wellikson, MD, CEO of SHM.
Consider this: Just a decade ago, there were about 100 pioneering hospitalists caring for patients in 20 hospitals. Today there are 20,000 hospitalists serving patients in 2,500 hospitals across the country. Hospital medicine is the fastest growing medical specialty in the United States. The time is right for hospitalists to rise to the fore—not just as leaders of their hospitalist groups but also as system-wide decision makers.
Stacy Goldsholl, MD, represents the new breed: hospitalist as leader. Dr. Goldsholl has been a hospitalist for 12 years. “I got my first job as a community hospitalist before the term was even coined,” she says. “After about five years, I really hit a low point in my career. I was dissatisfied with the way the system was working; I didn’t feel there was enough emphasis on quality patient care. I was at a crossroad. I even considered giving up medicine altogether and going to rabbinical school,” she says, laughing. “But I was very passionate about making things better, so instead of quitting medicine, I embarked on a solo jaunt around the country trying to interest people in improving hospital medicine.”
Today Dr. Goldsholl is president of the Hospital Medicine Division of TeamHealth (Knoxville, Tenn.), a nationwide outsourcing provider of hospitalists in areas as far flung as Puerto Rico and Hawaii.
Though there are no hard-and-fast statistics on how many hospitalists now have leadership roles, Dr. Wellikson says the numbers are swelling. “It’s getting harder and harder to find someone who has strong leadership skills who’s five years into practice who is still just seeing patients,” he says. “There’s such a crying need for leadership in managing the team, leading the hospital medicine group, improving the hospital, improving the quality of care … there’s an enormous void. The first time somebody shows up who has an interest or an aptitude, someone will say, ‘Why don’t you be in charge?’ ”
What Hospitalists Bring to the Leadership Table
Study after study indicates hospitals employing hospitalists experience an improvement in the bottom line that is due, in part, to greater efficiency. This is an important consideration in the current economic crunch in which many hospitals find themselves, but today there is an increased focus on improving patient care as well.
In both efficiency and patient care, hospitalists are uniquely positioned to bring something to the leadership table that other candidates might not. “Hospitalists have a holistic view of the hospital,” says Dr. Goldsholl. “Private physicians don’t have the same connectedness to all the parts. That kind of experience is very valuable. After all, that’s what the hospital is all about.”
Jack M. Percelay, MD, a member of SHM’s Board of Directors, puts it another way. “Clearly, administrative positions require some knowledge of hospital function,” he says. “On-site physicians are certainly more aware of where the problems are. They face them on a daily basis.”
Dr. Wellikson adds, “From the very beginning of their medical careers, even when their main role is seeing patients, hospitalists are looking at the hospital as a system as an institution. They may be members of a quality-improvement team or a group that looks at the flow of patients from the emergency room to the hospital. It becomes sort of second nature to them. Our doctors learn these competencies from the beginning. In their training and their involvement with SHM, whole sections are devoted to systems improvement, leadership, and things like that.”
Dr. Wellikson suggests a demographic reason so many hospitalists look forward to climbing the administrative ladder: “It’s the times. Older doctors may be counting the days till retirement, whereas most hospitalists are younger—the average age is 37—and they say, ‘Hey, I’m going to have 20 more years of this. If I don’t change things, who will?’
“I’ll give you an analogy. When you go to a hotel and your towels aren’t delivered, you might complain until you get them, but you don’t try to manage the hotel. That’s the way practicing doctors felt 20 years ago. But hospitalists, because they’re going to go to work every day in that hospital, if it’s not working tip-top, they’re going to get involved. It’s an evolution in healthcare.”
How to Become a Hospitalist Leader
We asked our experts what advice they would give hospitalists who aspire to critical decision-making positions. “Even if you have natural skills as a leader—you’re charismatic, you take on responsibility—leadership is a skill like any other,” says Dr. Wellikson. “Take the time early in your career to develop that skill. Get involved in some project you feel passionate about. Part of leadership is getting other people to move in the right direction and part is dealing with the people who won’t follow. That can be frustrating. See how this feels to you. Get the education you need, and don’t be afraid to fail. Everybody has failures.”
Dr. Percelay suggests finding activities in your group where you can take initiative. “Clinical legitimacy is key, too, together with a systems viewpoint,” he says. “I would also recommend CME [continuing medical education]-type activities to develop leadership skills. There are the [SHM] Leadership Academy, local business schools, and the American College of Physician Executives, but learn mostly by doing and participating. Joining national organizations is also helpful because you will interact with other like-minded individuals.”
Dr. Goldsholl advises hospitalists to be passionate about their beliefs and to have confidence in what they do. She remembers a seminar she attended at which the speaker—a prominent business executive—gave this advice: “If you’ve never been fired, you are afraid to stand up for what you believe.”
Decision-making positions require hard work and long hours, Dr. Goldsholl cautions. “You have to keep a balance between your personal life and your career. And never underestimate the power of networking at regional and national levels as well as locally. Make your voice heard in print and [at] speaking engagements too. Get published in the Journal of Hospital Medicine. People do read these articles.”
Trends for Hospitalists as Decision Makers
Everyone with whom we spoke predicts a bright future for hospitalists who want to become critical decision makers. “Hospitalists understand the important manifestations of the way all pieces fit together to impact even a single event,” says Dr. Goldsholl. “Already hospitalists are vice presidents of medical affairs, chief operating officers, and so forth. This trend toward placing hospitalists in management roles is being driven, in large part, by the institutional knowledge that hospitalists have. I expect the trend will only expand.”
“There is so much overlap in medicine that what I see developing is a spirit of collaboration,” says Dr. Percelay. “What’s good for the hospitalist is good for the hospital and ultimately good for the patient. I believe that an alignment of incentives is driving the trend toward the appointment of hospitalists to general leadership positions.”
Hospitalists can create a healthcare system driven by teams of healthcare professionals and based on delivering measurable quality, according to Dr. Wellikson, who says hospitalists will play a major role in leading the quality revolution in this country. “We are moving to a time when business and Medicare are driving toward pay for performance,” he says. “Not just, ‘Did you do the surgery?’ but, ‘How well did you do the surgery?’ ”
Most importantly, Dr. Wellikson believes hospitalists are positioned incredibly well to be leaders in this movement. “The first thing people have to do is agree there is a problem. Then they have to measure the performance, try to improve the situation, and then measure the performance again. This is the wave of the future. We [hospitalists] are working with the government, with the National Quality Forum, with the Institute for Healthcare Improvement. Improvement in quality of care is the number one trend upon which hospitalist leaders will have an impact.”
Another emerging trend: Hospitalist decision makers will influence a redesigned hospital of the future. (Dr. Wellikson is one of 20 people on the Joint Commission Hospital of the Future Work Group.) “The hospital of the future will be very different,” explains Dr. Wellikson. “There’s going to be a home team in the new hospital. It will consist of the ED doctors, critical-care doctors, and hospitalists, working with nurses, pharmacists, and the administration as a team to deliver more technology and do more for sicker people.”
These efforts will be on a collision course with the hospital’s ability to afford them, he believes, so hospitalist leadership will be key to creating an efficient hospital that uses its resources in the best way possible and works as a team.
As more and more hospitalists gravitate toward hospitalwide leadership positions, they will confront some of their own. “It’s going to be very interesting,” says Dr. Percelay, “when the hospital medicine group leader differs with the vice president of medical affairs and they both share the same background. The hospital medicine group leader will no longer be able to say, ‘You don’t know where I’m coming from.’ ” TH
Joen Kinnan is a medical journalist based in Chicago.
Sentinel Events
In July, a teenage mother-to-be entered a Madison, Wis., hospital to give birth. Within hours she was dead, though her baby survived.
An investigation by the Wisconsin State Department of Health revealed that the young woman had died after receiving an intravenous dose of an epidural anesthetic instead of the penicillin she was supposed to be given. Shortly after receiving the injection, the teenager had a seizure. She died less than two hours later.
In explaining what had happened, a nurse told investigators that the patient had been nervous about how she was to be anesthetized during the birth. To ease her concerns, the nurse brought out the epidural bag and told her how it worked. Unfortunately, it was one bag too many; the nurse later confused the epidural bag with the penicillin bag. The consequences were fatal.
The Human Toll
Such sentinel events are all too common. According to a just-released report, Preventing Medication Errors, prepared by the Institute of Medicine (IOM) at the behest of the Centers for Medicare and Medicaid Services, medication errors harm 1.5 million people yearly in the U.S. and kill thousands. The annual cost: at least $3.5 billion. But medication mistakes are just part of the picture.
Sentinel events—unexpected occurrences that result in death or serious physical or psychological injury, or the risk of their later occurrence—can happen anywhere along the healthcare continuum, in any setting. Statistics from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), however, show that 68% occur in general hospitals and another 11% in psychiatric hospitals. JCAHO tracked the sentinel events they reviewed from 1995 to March of 2006 and found that the most commonly reported sentinel events were patient suicide, wrong-site surgery, operative/postoperative complications, medication errors, and delay in treatment—in that order. Of the total number of cases reviewed, 73% resulted in the death of the patient and 10% in loss of function.
Hard-and-fast statistics on sentinel events are difficult to come by, however. Information from the JCAHO covers only the incidents reviewed by that organization, and experts agree that almost all types of sentinel events are under-reported. Researchers cite a number of reasons that many incidents go unreported; among them are lack of time, fear of punishment, and confusion about the severity of events that require notification. For example, do near misses count? (See “Near Misses,” The Hospitalist, May, p. 34.) Others see no benefit to themselves or their institutions from reporting.
Studies have attempted to define the true incidence of sentinel events, but a lack of consistent language and definitions makes it difficult to put the whole puzzle together, even when sentinel events do come to the surface.
Focus on Medication Errors
That said, we know that the incidence of sentinel events is much higher than it should be. As regularly reported by The Hospitalist, the problem most in the spotlight today—among researchers and the popular press—is medication errors. The IOM report says that, on average, a hospitalized patient is subject to at least one medication error per day, though error rates vary widely among hospitals. Fortunately, most errors cause no serious harm, but the costs for those that do are substantial. One study found that each preventable adverse drug event (ADE) costs a hospital approximately $8,750.
At least a quarter of medication-related injuries are preventable, according to the report. The irony is that many error-prevention methods are available today: “do not use” abbreviation lists; medication reconciliation (used to compare a patient’s medication orders with all other medications the patient is taking in order to avoid omissions, duplications, dosing errors, or drug interactions); and computerized physician order entry systems, to name a few.
With so much emphasis on patient safety and the increasing availability of sophisticated reporting and record-keeping technology, why haven’t incidence rates for ADEs and other sentinel events dropped dramatically? The answer is not that hospital personnel are lazy, incompetent, or indifferent to the safety of their patients. Experts agree that today’s doctors, nurses, pharmacists, and other medical staff are highly trained, dedicated professionals who want to practice the best medicine possible. The present system focuses on individual fault and does not foster disclosure that could lead to corrective procedures.
In fact, legal experts worry that JCAHO’s Sentinel Events Policy, which mandates self-reporting by hospitals accredited by the JCAHO, creates new problems. They suggest that self-reporting will have limited success in the absence of immunity from legal liability. One proposed solution calls for submitting self-regulatory reports to a neutral, nonsanctioning third-party entity. This approach has worked well for the airline industry.
New Patient-Care Focus
Abandoning a policy that concentrates on blame is at the heart of the improvements in patient safety proposed in the IOM report. Rather than pinpointing individual error, the new paradigm focuses on developing new systems of care that foster patient safety and help prevent sentinel events. In the absence of a finger-pointing environment, hospital personnel can freely examine what happened, discover the causes, and structure new procedures to prevent future occurrences – without fear of any retribution.
That’s the way they handle it at California Pacific Medical Center in San Francisco. In one case, when a nurse removed a dialysis catheter, the patient developed an air embolism and subsequently suffered a severe, permanently disabling stroke.
“When we investigated, we found that there was a written procedure in place to document a dialysis nurse’s credential,” says hospitalist Thomas E. Baudendistel, MD, FCAP, who is associate medical director of the hospital’s Internal Medicine Residency Program. “A, we weren’t aware of the credentialing procedure, and B, when we looked at it we weren’t sure it represented best practice. So we researched the literature and rewrote the policy. Now we schedule regular nursing education on pulling a dialysis catheter.”
In addition, the hospital set in place a follow-up plan to re-evaluate the procedure periodically. They also offer refresher training in catheter removal.
“We’ve used a similar approach in other situations,” says Dr. Baudendistel. “For example, our procedure with falls has changed. Now we use an event-based algorithm to determine whether a head CT scan is necessary.”
Hospitalists Can Lead
Hospital-based physicians are in an advantageous position to promote—as well as participate in—new initiatives for patient safety. Because they are involved in the day-to-day care of patients, hospitalists are firsthand observers when many errors occur. They have the experience and clinical judgment to give meaningful input to new incident-reporting protocols and to promote new policies through interdisciplinary teams that investigate and analyze adverse events.
Inevitably, electronic systems will replace paper-and-pen reporting and recordkeeping. Here hospitalists can take the lead, too. Unlike physicians who admit patients to multiple hospitals (each with a different information system), hospitalists practice in a single institution with only one system to learn. Hospitalists’ patient load may also help them to master new technology more quickly.
Surveys show that, while many hospitals have electronic ordering systems in place, relatively few physicians actually use them. In many cases, nurses or pharmacists place the electronic orders. Hospitalists who place their own orders can contribute to a reduction in medication errors by eliminating the pass-through of information that often causes misunderstandings.
Patient-Centric Healthcare: the New Paradigm
The traditional hospital system—and the healthcare system as a whole—are provider-oriented and provider-directed. Many patients, especially older ones, have a “doctor knows all” mindset, and they typically ask few questions—even when they don’t understand their treatment plans or exactly how they’re to take their medications when they go home. Case in point: A patient who was discharged from the hospital died at home shortly thereafter. The cause: His wife misunderstood the instructions for his pain medication and mistakenly applied six transdermal patches to his skin at one time instead of the single patch she should have applied. The multiple patches delivered a fatal overdose of the narcotic fentanyl.
Many experts believe that better informed—and empowered—patients are the key to reducing the number of sentinel events, including ADEs. The IOM report advocates a shift from a provider-centered to a patient-centered healthcare model. In this new paradigm, hospitalists would be much more expansive in their communications with patients. With regard to medications in particular, the report recommends that a physician:
- Review the patient’s medication list routinely and during care transitions.
- Review different treatment options.
- Review the names and purposes of all medications.
- Discuss when and how to take the medication.
- Discuss important and likely side effects and what to do about them.
- Discuss drug-drug, drug-food, and drug-disease interactions.
- Review the patient’s (or surrogate’s) role in appropriate medication use.
- Review the role of medications in the overall context of the patient’s health.
There are barriers to surmount before patients can become full partners in their healthcare. One of the most obvious is that patients need to be much better informed, and—when they are incapable of making appropriate decisions—they need surrogates to stand in for them. Patients need access to trustworthy and understandable information both online and in printed materials.
The IOM report recommends a government-sponsored national drug-information hotline; medication leaflets that provide standardized language in a manner that is appropriate for various age, literacy, and visual acuity levels; and development of personal health records.
PeaceHealth in Washington state took up the challenge of developing personal health records in 2001. PeaceHealth’s Project Manager, Mary Minniti, invited patients to design the system for self-management and communication among care team members. Today, the Shared Care Plan Personal Health Record is a reality, and Marc Pierson, MD, who is PeaceHealth’s regional vice president of Clinical Information and Special Projects, says “early evidence suggests that this type of tool promotes personal responsibility and positively affects patients’ confidence and active participation in their care.”
The tool is available on CD from www.peacehealth.org for those who would like to adopt it for their use.
Final Thought
The bad news is that sentinel events still take a staggering human and economic toll. The good news is that momentum is building for an important change in the way healthcare is delivered. Better communication, new technologies, and, perhaps most importantly, true provider-patient partnerships hold the promise of making hospital healthcare much safer. Hospitalists play a key role in this new scenario. TH
Joen Kinnan is a freelance medical writer based in Chicago.
In July, a teenage mother-to-be entered a Madison, Wis., hospital to give birth. Within hours she was dead, though her baby survived.
An investigation by the Wisconsin State Department of Health revealed that the young woman had died after receiving an intravenous dose of an epidural anesthetic instead of the penicillin she was supposed to be given. Shortly after receiving the injection, the teenager had a seizure. She died less than two hours later.
In explaining what had happened, a nurse told investigators that the patient had been nervous about how she was to be anesthetized during the birth. To ease her concerns, the nurse brought out the epidural bag and told her how it worked. Unfortunately, it was one bag too many; the nurse later confused the epidural bag with the penicillin bag. The consequences were fatal.
The Human Toll
Such sentinel events are all too common. According to a just-released report, Preventing Medication Errors, prepared by the Institute of Medicine (IOM) at the behest of the Centers for Medicare and Medicaid Services, medication errors harm 1.5 million people yearly in the U.S. and kill thousands. The annual cost: at least $3.5 billion. But medication mistakes are just part of the picture.
Sentinel events—unexpected occurrences that result in death or serious physical or psychological injury, or the risk of their later occurrence—can happen anywhere along the healthcare continuum, in any setting. Statistics from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), however, show that 68% occur in general hospitals and another 11% in psychiatric hospitals. JCAHO tracked the sentinel events they reviewed from 1995 to March of 2006 and found that the most commonly reported sentinel events were patient suicide, wrong-site surgery, operative/postoperative complications, medication errors, and delay in treatment—in that order. Of the total number of cases reviewed, 73% resulted in the death of the patient and 10% in loss of function.
Hard-and-fast statistics on sentinel events are difficult to come by, however. Information from the JCAHO covers only the incidents reviewed by that organization, and experts agree that almost all types of sentinel events are under-reported. Researchers cite a number of reasons that many incidents go unreported; among them are lack of time, fear of punishment, and confusion about the severity of events that require notification. For example, do near misses count? (See “Near Misses,” The Hospitalist, May, p. 34.) Others see no benefit to themselves or their institutions from reporting.
Studies have attempted to define the true incidence of sentinel events, but a lack of consistent language and definitions makes it difficult to put the whole puzzle together, even when sentinel events do come to the surface.
Focus on Medication Errors
That said, we know that the incidence of sentinel events is much higher than it should be. As regularly reported by The Hospitalist, the problem most in the spotlight today—among researchers and the popular press—is medication errors. The IOM report says that, on average, a hospitalized patient is subject to at least one medication error per day, though error rates vary widely among hospitals. Fortunately, most errors cause no serious harm, but the costs for those that do are substantial. One study found that each preventable adverse drug event (ADE) costs a hospital approximately $8,750.
At least a quarter of medication-related injuries are preventable, according to the report. The irony is that many error-prevention methods are available today: “do not use” abbreviation lists; medication reconciliation (used to compare a patient’s medication orders with all other medications the patient is taking in order to avoid omissions, duplications, dosing errors, or drug interactions); and computerized physician order entry systems, to name a few.
With so much emphasis on patient safety and the increasing availability of sophisticated reporting and record-keeping technology, why haven’t incidence rates for ADEs and other sentinel events dropped dramatically? The answer is not that hospital personnel are lazy, incompetent, or indifferent to the safety of their patients. Experts agree that today’s doctors, nurses, pharmacists, and other medical staff are highly trained, dedicated professionals who want to practice the best medicine possible. The present system focuses on individual fault and does not foster disclosure that could lead to corrective procedures.
In fact, legal experts worry that JCAHO’s Sentinel Events Policy, which mandates self-reporting by hospitals accredited by the JCAHO, creates new problems. They suggest that self-reporting will have limited success in the absence of immunity from legal liability. One proposed solution calls for submitting self-regulatory reports to a neutral, nonsanctioning third-party entity. This approach has worked well for the airline industry.
New Patient-Care Focus
Abandoning a policy that concentrates on blame is at the heart of the improvements in patient safety proposed in the IOM report. Rather than pinpointing individual error, the new paradigm focuses on developing new systems of care that foster patient safety and help prevent sentinel events. In the absence of a finger-pointing environment, hospital personnel can freely examine what happened, discover the causes, and structure new procedures to prevent future occurrences – without fear of any retribution.
That’s the way they handle it at California Pacific Medical Center in San Francisco. In one case, when a nurse removed a dialysis catheter, the patient developed an air embolism and subsequently suffered a severe, permanently disabling stroke.
“When we investigated, we found that there was a written procedure in place to document a dialysis nurse’s credential,” says hospitalist Thomas E. Baudendistel, MD, FCAP, who is associate medical director of the hospital’s Internal Medicine Residency Program. “A, we weren’t aware of the credentialing procedure, and B, when we looked at it we weren’t sure it represented best practice. So we researched the literature and rewrote the policy. Now we schedule regular nursing education on pulling a dialysis catheter.”
In addition, the hospital set in place a follow-up plan to re-evaluate the procedure periodically. They also offer refresher training in catheter removal.
“We’ve used a similar approach in other situations,” says Dr. Baudendistel. “For example, our procedure with falls has changed. Now we use an event-based algorithm to determine whether a head CT scan is necessary.”
Hospitalists Can Lead
Hospital-based physicians are in an advantageous position to promote—as well as participate in—new initiatives for patient safety. Because they are involved in the day-to-day care of patients, hospitalists are firsthand observers when many errors occur. They have the experience and clinical judgment to give meaningful input to new incident-reporting protocols and to promote new policies through interdisciplinary teams that investigate and analyze adverse events.
Inevitably, electronic systems will replace paper-and-pen reporting and recordkeeping. Here hospitalists can take the lead, too. Unlike physicians who admit patients to multiple hospitals (each with a different information system), hospitalists practice in a single institution with only one system to learn. Hospitalists’ patient load may also help them to master new technology more quickly.
Surveys show that, while many hospitals have electronic ordering systems in place, relatively few physicians actually use them. In many cases, nurses or pharmacists place the electronic orders. Hospitalists who place their own orders can contribute to a reduction in medication errors by eliminating the pass-through of information that often causes misunderstandings.
Patient-Centric Healthcare: the New Paradigm
The traditional hospital system—and the healthcare system as a whole—are provider-oriented and provider-directed. Many patients, especially older ones, have a “doctor knows all” mindset, and they typically ask few questions—even when they don’t understand their treatment plans or exactly how they’re to take their medications when they go home. Case in point: A patient who was discharged from the hospital died at home shortly thereafter. The cause: His wife misunderstood the instructions for his pain medication and mistakenly applied six transdermal patches to his skin at one time instead of the single patch she should have applied. The multiple patches delivered a fatal overdose of the narcotic fentanyl.
Many experts believe that better informed—and empowered—patients are the key to reducing the number of sentinel events, including ADEs. The IOM report advocates a shift from a provider-centered to a patient-centered healthcare model. In this new paradigm, hospitalists would be much more expansive in their communications with patients. With regard to medications in particular, the report recommends that a physician:
- Review the patient’s medication list routinely and during care transitions.
- Review different treatment options.
- Review the names and purposes of all medications.
- Discuss when and how to take the medication.
- Discuss important and likely side effects and what to do about them.
- Discuss drug-drug, drug-food, and drug-disease interactions.
- Review the patient’s (or surrogate’s) role in appropriate medication use.
- Review the role of medications in the overall context of the patient’s health.
There are barriers to surmount before patients can become full partners in their healthcare. One of the most obvious is that patients need to be much better informed, and—when they are incapable of making appropriate decisions—they need surrogates to stand in for them. Patients need access to trustworthy and understandable information both online and in printed materials.
The IOM report recommends a government-sponsored national drug-information hotline; medication leaflets that provide standardized language in a manner that is appropriate for various age, literacy, and visual acuity levels; and development of personal health records.
PeaceHealth in Washington state took up the challenge of developing personal health records in 2001. PeaceHealth’s Project Manager, Mary Minniti, invited patients to design the system for self-management and communication among care team members. Today, the Shared Care Plan Personal Health Record is a reality, and Marc Pierson, MD, who is PeaceHealth’s regional vice president of Clinical Information and Special Projects, says “early evidence suggests that this type of tool promotes personal responsibility and positively affects patients’ confidence and active participation in their care.”
The tool is available on CD from www.peacehealth.org for those who would like to adopt it for their use.
Final Thought
The bad news is that sentinel events still take a staggering human and economic toll. The good news is that momentum is building for an important change in the way healthcare is delivered. Better communication, new technologies, and, perhaps most importantly, true provider-patient partnerships hold the promise of making hospital healthcare much safer. Hospitalists play a key role in this new scenario. TH
Joen Kinnan is a freelance medical writer based in Chicago.
In July, a teenage mother-to-be entered a Madison, Wis., hospital to give birth. Within hours she was dead, though her baby survived.
An investigation by the Wisconsin State Department of Health revealed that the young woman had died after receiving an intravenous dose of an epidural anesthetic instead of the penicillin she was supposed to be given. Shortly after receiving the injection, the teenager had a seizure. She died less than two hours later.
In explaining what had happened, a nurse told investigators that the patient had been nervous about how she was to be anesthetized during the birth. To ease her concerns, the nurse brought out the epidural bag and told her how it worked. Unfortunately, it was one bag too many; the nurse later confused the epidural bag with the penicillin bag. The consequences were fatal.
The Human Toll
Such sentinel events are all too common. According to a just-released report, Preventing Medication Errors, prepared by the Institute of Medicine (IOM) at the behest of the Centers for Medicare and Medicaid Services, medication errors harm 1.5 million people yearly in the U.S. and kill thousands. The annual cost: at least $3.5 billion. But medication mistakes are just part of the picture.
Sentinel events—unexpected occurrences that result in death or serious physical or psychological injury, or the risk of their later occurrence—can happen anywhere along the healthcare continuum, in any setting. Statistics from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), however, show that 68% occur in general hospitals and another 11% in psychiatric hospitals. JCAHO tracked the sentinel events they reviewed from 1995 to March of 2006 and found that the most commonly reported sentinel events were patient suicide, wrong-site surgery, operative/postoperative complications, medication errors, and delay in treatment—in that order. Of the total number of cases reviewed, 73% resulted in the death of the patient and 10% in loss of function.
Hard-and-fast statistics on sentinel events are difficult to come by, however. Information from the JCAHO covers only the incidents reviewed by that organization, and experts agree that almost all types of sentinel events are under-reported. Researchers cite a number of reasons that many incidents go unreported; among them are lack of time, fear of punishment, and confusion about the severity of events that require notification. For example, do near misses count? (See “Near Misses,” The Hospitalist, May, p. 34.) Others see no benefit to themselves or their institutions from reporting.
Studies have attempted to define the true incidence of sentinel events, but a lack of consistent language and definitions makes it difficult to put the whole puzzle together, even when sentinel events do come to the surface.
Focus on Medication Errors
That said, we know that the incidence of sentinel events is much higher than it should be. As regularly reported by The Hospitalist, the problem most in the spotlight today—among researchers and the popular press—is medication errors. The IOM report says that, on average, a hospitalized patient is subject to at least one medication error per day, though error rates vary widely among hospitals. Fortunately, most errors cause no serious harm, but the costs for those that do are substantial. One study found that each preventable adverse drug event (ADE) costs a hospital approximately $8,750.
At least a quarter of medication-related injuries are preventable, according to the report. The irony is that many error-prevention methods are available today: “do not use” abbreviation lists; medication reconciliation (used to compare a patient’s medication orders with all other medications the patient is taking in order to avoid omissions, duplications, dosing errors, or drug interactions); and computerized physician order entry systems, to name a few.
With so much emphasis on patient safety and the increasing availability of sophisticated reporting and record-keeping technology, why haven’t incidence rates for ADEs and other sentinel events dropped dramatically? The answer is not that hospital personnel are lazy, incompetent, or indifferent to the safety of their patients. Experts agree that today’s doctors, nurses, pharmacists, and other medical staff are highly trained, dedicated professionals who want to practice the best medicine possible. The present system focuses on individual fault and does not foster disclosure that could lead to corrective procedures.
In fact, legal experts worry that JCAHO’s Sentinel Events Policy, which mandates self-reporting by hospitals accredited by the JCAHO, creates new problems. They suggest that self-reporting will have limited success in the absence of immunity from legal liability. One proposed solution calls for submitting self-regulatory reports to a neutral, nonsanctioning third-party entity. This approach has worked well for the airline industry.
New Patient-Care Focus
Abandoning a policy that concentrates on blame is at the heart of the improvements in patient safety proposed in the IOM report. Rather than pinpointing individual error, the new paradigm focuses on developing new systems of care that foster patient safety and help prevent sentinel events. In the absence of a finger-pointing environment, hospital personnel can freely examine what happened, discover the causes, and structure new procedures to prevent future occurrences – without fear of any retribution.
That’s the way they handle it at California Pacific Medical Center in San Francisco. In one case, when a nurse removed a dialysis catheter, the patient developed an air embolism and subsequently suffered a severe, permanently disabling stroke.
“When we investigated, we found that there was a written procedure in place to document a dialysis nurse’s credential,” says hospitalist Thomas E. Baudendistel, MD, FCAP, who is associate medical director of the hospital’s Internal Medicine Residency Program. “A, we weren’t aware of the credentialing procedure, and B, when we looked at it we weren’t sure it represented best practice. So we researched the literature and rewrote the policy. Now we schedule regular nursing education on pulling a dialysis catheter.”
In addition, the hospital set in place a follow-up plan to re-evaluate the procedure periodically. They also offer refresher training in catheter removal.
“We’ve used a similar approach in other situations,” says Dr. Baudendistel. “For example, our procedure with falls has changed. Now we use an event-based algorithm to determine whether a head CT scan is necessary.”
Hospitalists Can Lead
Hospital-based physicians are in an advantageous position to promote—as well as participate in—new initiatives for patient safety. Because they are involved in the day-to-day care of patients, hospitalists are firsthand observers when many errors occur. They have the experience and clinical judgment to give meaningful input to new incident-reporting protocols and to promote new policies through interdisciplinary teams that investigate and analyze adverse events.
Inevitably, electronic systems will replace paper-and-pen reporting and recordkeeping. Here hospitalists can take the lead, too. Unlike physicians who admit patients to multiple hospitals (each with a different information system), hospitalists practice in a single institution with only one system to learn. Hospitalists’ patient load may also help them to master new technology more quickly.
Surveys show that, while many hospitals have electronic ordering systems in place, relatively few physicians actually use them. In many cases, nurses or pharmacists place the electronic orders. Hospitalists who place their own orders can contribute to a reduction in medication errors by eliminating the pass-through of information that often causes misunderstandings.
Patient-Centric Healthcare: the New Paradigm
The traditional hospital system—and the healthcare system as a whole—are provider-oriented and provider-directed. Many patients, especially older ones, have a “doctor knows all” mindset, and they typically ask few questions—even when they don’t understand their treatment plans or exactly how they’re to take their medications when they go home. Case in point: A patient who was discharged from the hospital died at home shortly thereafter. The cause: His wife misunderstood the instructions for his pain medication and mistakenly applied six transdermal patches to his skin at one time instead of the single patch she should have applied. The multiple patches delivered a fatal overdose of the narcotic fentanyl.
Many experts believe that better informed—and empowered—patients are the key to reducing the number of sentinel events, including ADEs. The IOM report advocates a shift from a provider-centered to a patient-centered healthcare model. In this new paradigm, hospitalists would be much more expansive in their communications with patients. With regard to medications in particular, the report recommends that a physician:
- Review the patient’s medication list routinely and during care transitions.
- Review different treatment options.
- Review the names and purposes of all medications.
- Discuss when and how to take the medication.
- Discuss important and likely side effects and what to do about them.
- Discuss drug-drug, drug-food, and drug-disease interactions.
- Review the patient’s (or surrogate’s) role in appropriate medication use.
- Review the role of medications in the overall context of the patient’s health.
There are barriers to surmount before patients can become full partners in their healthcare. One of the most obvious is that patients need to be much better informed, and—when they are incapable of making appropriate decisions—they need surrogates to stand in for them. Patients need access to trustworthy and understandable information both online and in printed materials.
The IOM report recommends a government-sponsored national drug-information hotline; medication leaflets that provide standardized language in a manner that is appropriate for various age, literacy, and visual acuity levels; and development of personal health records.
PeaceHealth in Washington state took up the challenge of developing personal health records in 2001. PeaceHealth’s Project Manager, Mary Minniti, invited patients to design the system for self-management and communication among care team members. Today, the Shared Care Plan Personal Health Record is a reality, and Marc Pierson, MD, who is PeaceHealth’s regional vice president of Clinical Information and Special Projects, says “early evidence suggests that this type of tool promotes personal responsibility and positively affects patients’ confidence and active participation in their care.”
The tool is available on CD from www.peacehealth.org for those who would like to adopt it for their use.
Final Thought
The bad news is that sentinel events still take a staggering human and economic toll. The good news is that momentum is building for an important change in the way healthcare is delivered. Better communication, new technologies, and, perhaps most importantly, true provider-patient partnerships hold the promise of making hospital healthcare much safer. Hospitalists play a key role in this new scenario. TH
Joen Kinnan is a freelance medical writer based in Chicago.