John Nelson, MD.

The vacation conundrum most people face has to do with things like whether to drive or fly, or whether to sleep on the ground or in a hotel. But some hospitalists encounter tricky problems when figuring out how to operationalize their contractual provision for vacation time.

What is the Vacation Conundrum?

I’m a big believer in hospitalists having liberal amounts of time off, but I think most practices should avoid contractually specifying vacation time. This may sound contradictory and terribly unfair to the doctor. But avoiding a contractual guarantee of vacation time doesn’t mean the hospitalist gets any less time off. And the way hospitalist contracts address vacation time has gotten a lot of organizations in trouble. Let me explain.

Contracts often stipulate that a hospitalist will have a specified number of weeks of vacation time annually, and this language has usually been taken from the organization’s existing contracts with other physicians. But confusion often arises some time after the hospitalist practice is up and running. One big problem is deciding who will cover for the hospitalist on vacation. If all doctors work extra shifts to cover for a member of the practice who is on vacation, they will all take turns working extra—a practice that negates the effect of the promised holiday. Another problem is that most hospitalists follow non-traditional work schedules, making it difficult to determine which of the days not worked are vacation days and which are days the doctor just wasn’t scheduled to work.

To better understand this issue, it is worth thinking about how most hospitalist schedules differ from that of a typical office-based doctor or businessperson. Someone in business is usually expected to work every Monday through Friday of the year—except government holidays. Those weekdays that the business person doesn’t work are usually regarded as vacation days. (Note that I’m intentionally ignoring sick time in this discussion.) Weekend days are almost never regarded as vacation days in the business world.

But things are far more complicated for hospitalists because of the non-traditional—not always Monday through Friday—schedule they work. If a hospitalist has Tuesday and Wednesday off this week, should that be counted as vacation time or simply weekend days displaced into the middle of the week because the doctor worked the prior weekend? It is often impossible to answer this question unambiguously.

Another issue to be considered is that decisions about vacation time and the normal—non-vacation—schedule the hospitalists use are often made independently. For example, many groups use a seven days on-seven days off schedule, with 12-hour shifts on each worked day. This might lead to an agreement that every seven worked days will count as two weeks of work that has been compressed into one week on the calendar. If that’s the case, debate can arise when trying to figure out what one week of vacation really means.

One could reasonably argue that it means the doctor is relieved of five days of work, because in most jobs a week off means being off Monday through Friday. Or, because every seven worked days counts as two weeks of work, a week off could mean being relieved of half of those days—or 3.5 days off. Lastly, a hospitalist could reasonably argue that a week off means being relieved of all seven days of one of the worked weeks. This last approach is the most common way the issue is handled. Specifying vacation in numbers of days or hours, rather than in numbers of weeks, helps but does not eliminate this confusion.

Things can get really tricky when hospitalists start adjusting their standard work schedule. They might shorten or lengthen certain existing shifts or add new shifts (e.g., an evening admitting shift) all of which complicates figuring out what a day or week of vacation really means. Think about a group that has a standard schedule of 10-hour day shifts, 14-hour night shifts, and a six-hour evening admitting shift (e.g., 5 p.m. to 11 p.m.). What will a day or week of vacation mean for them? Maybe they could specify a certain number of hours of vacation rather than days or weeks. That would be useful only for practices that contract for doctors to work a specified number of hours annually, which is probably not the best way to organize a hospitalist’s work. And hours of vacation time can get pretty complicated because doctors usually don’t regard an hour of a day shift as equivalent to an hour of the night or evening shift.

I have a great relationship with a hospital executive who works a Monday-through-Friday schedule. For years, when she noticed that I had been off for a few days, she would always ask if I had just gotten back from “vacation.” I wouldn’t bother to explain to her that it usually wasn’t vacation; it was just days I wasn’t scheduled to work to make up for working 12 to 20 consecutive days. But after about a year of her asking me about my vacation every two or three weeks, she mentioned how much she envied that I had so much vacation time, when in fact I had worked more days that year—had less time off and less vacation time—than she had. I could have taken the time to respond to each of her inquiries about my vacations by explaining which were just days I wasn’t scheduled to work and which really were vacation days. But the distinction is really arbitrary. As long as I’m getting enough time off—a lot—how each of those days is labeled doesn’t really matter.

Solutions to the Vacation Conundrum

I think it’s best to use one of the following two approaches to avoid confusion about vacation time:

1. Specify how many shifts—or other work periods—the hospitalist is expected to work monthly or annually; or
2. Agree—perhaps in a contract—that each hospitalist will work the same number of days (shifts) annually unless doctors mutually decide to do otherwise.

All of the other days can be thought of as days not scheduled to work—weekends, if you will, even if the days off occur during the week instead of Saturday and Sunday—vacation days, or even CME days. That way there is no need to keep track of how the days not worked are labeled or classified.

Full-time hospitalists in the group I am part of work 210 days annually. After I explain our schedule to a prospective new member of the group, I’m often asked how much vacation a new hire will get. I explain that we just specify how much work is expected of a doctor, and the non-worked days can be classified any way they would like. Understandably, some people really want a provision for vacation in the contract, so I will sometimes ask them to tell me how many vacation days they would like annually. If they say they’d like 21 days of vacation, I tell them that will be fine. We will write the contract to reflect the 231 days they are expected to work annually, but they will have 21 days of vacation. So they’re back to working the same 210 days a year that the rest of us work.

Summary

If your current contract specifies numbers of days—or weeks or hours—of vacation time and that works well, without any confusion about what constitutes a vacation day, then there is no reason to change anything right now. But you should think about what a day of vacation might mean if you change your current schedule a great deal—if you changed the duration of shifts, for example. If that might cast uncertainty on what a day of vacation means, then consider developing a contract that is silent on vacation and just specifies how much work is expected of the doctor.

I want to emphasize again that a hospitalist will have exactly the same amount of time off for vacation or any other purpose in a contract that just specifies the number of shifts/days worked and is silent on vacation time. This does not take anything away from the doctor. It is simply a different way to address the issue in the contract, while eliminating a lot of potential confusion and frustration.

If you want to know if this is really a reasonable and workable approach to vacation time, you should talk with the emergency department (ED) doctors at your hospital. If you ask them how much vacation they get, they’re likely to look puzzled and say something like, “I don’t know how much vacation time I get. All I know is that I work 14 shifts a month.” Years ago, the non-traditional working schedule used by ED doctors led many or most groups to adopt the approach to vacation I’m suggesting for hospitalists. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

The vacation conundrum most people face has to do with things like whether to drive or fly, or whether to sleep on the ground or in a hotel. But some hospitalists encounter tricky problems when figuring out how to operationalize their contractual provision for vacation time.

What is the Vacation Conundrum?

I’m a big believer in hospitalists having liberal amounts of time off, but I think most practices should avoid contractually specifying vacation time. This may sound contradictory and terribly unfair to the doctor. But avoiding a contractual guarantee of vacation time doesn’t mean the hospitalist gets any less time off. And the way hospitalist contracts address vacation time has gotten a lot of organizations in trouble. Let me explain.

Contracts often stipulate that a hospitalist will have a specified number of weeks of vacation time annually, and this language has usually been taken from the organization’s existing contracts with other physicians. But confusion often arises some time after the hospitalist practice is up and running. One big problem is deciding who will cover for the hospitalist on vacation. If all doctors work extra shifts to cover for a member of the practice who is on vacation, they will all take turns working extra—a practice that negates the effect of the promised holiday. Another problem is that most hospitalists follow non-traditional work schedules, making it difficult to determine which of the days not worked are vacation days and which are days the doctor just wasn’t scheduled to work.

To better understand this issue, it is worth thinking about how most hospitalist schedules differ from that of a typical office-based doctor or businessperson. Someone in business is usually expected to work every Monday through Friday of the year—except government holidays. Those weekdays that the business person doesn’t work are usually regarded as vacation days. (Note that I’m intentionally ignoring sick time in this discussion.) Weekend days are almost never regarded as vacation days in the business world.

But things are far more complicated for hospitalists because of the non-traditional—not always Monday through Friday—schedule they work. If a hospitalist has Tuesday and Wednesday off this week, should that be counted as vacation time or simply weekend days displaced into the middle of the week because the doctor worked the prior weekend? It is often impossible to answer this question unambiguously.

Another issue to be considered is that decisions about vacation time and the normal—non-vacation—schedule the hospitalists use are often made independently. For example, many groups use a seven days on-seven days off schedule, with 12-hour shifts on each worked day. This might lead to an agreement that every seven worked days will count as two weeks of work that has been compressed into one week on the calendar. If that’s the case, debate can arise when trying to figure out what one week of vacation really means.

One could reasonably argue that it means the doctor is relieved of five days of work, because in most jobs a week off means being off Monday through Friday. Or, because every seven worked days counts as two weeks of work, a week off could mean being relieved of half of those days—or 3.5 days off. Lastly, a hospitalist could reasonably argue that a week off means being relieved of all seven days of one of the worked weeks. This last approach is the most common way the issue is handled. Specifying vacation in numbers of days or hours, rather than in numbers of weeks, helps but does not eliminate this confusion.

Things can get really tricky when hospitalists start adjusting their standard work schedule. They might shorten or lengthen certain existing shifts or add new shifts (e.g., an evening admitting shift) all of which complicates figuring out what a day or week of vacation really means. Think about a group that has a standard schedule of 10-hour day shifts, 14-hour night shifts, and a six-hour evening admitting shift (e.g., 5 p.m. to 11 p.m.). What will a day or week of vacation mean for them? Maybe they could specify a certain number of hours of vacation rather than days or weeks. That would be useful only for practices that contract for doctors to work a specified number of hours annually, which is probably not the best way to organize a hospitalist’s work. And hours of vacation time can get pretty complicated because doctors usually don’t regard an hour of a day shift as equivalent to an hour of the night or evening shift.

I have a great relationship with a hospital executive who works a Monday-through-Friday schedule. For years, when she noticed that I had been off for a few days, she would always ask if I had just gotten back from “vacation.” I wouldn’t bother to explain to her that it usually wasn’t vacation; it was just days I wasn’t scheduled to work to make up for working 12 to 20 consecutive days. But after about a year of her asking me about my vacation every two or three weeks, she mentioned how much she envied that I had so much vacation time, when in fact I had worked more days that year—had less time off and less vacation time—than she had. I could have taken the time to respond to each of her inquiries about my vacations by explaining which were just days I wasn’t scheduled to work and which really were vacation days. But the distinction is really arbitrary. As long as I’m getting enough time off—a lot—how each of those days is labeled doesn’t really matter.

Solutions to the Vacation Conundrum

I think it’s best to use one of the following two approaches to avoid confusion about vacation time:

1. Specify how many shifts—or other work periods—the hospitalist is expected to work monthly or annually; or
2. Agree—perhaps in a contract—that each hospitalist will work the same number of days (shifts) annually unless doctors mutually decide to do otherwise.

All of the other days can be thought of as days not scheduled to work—weekends, if you will, even if the days off occur during the week instead of Saturday and Sunday—vacation days, or even CME days. That way there is no need to keep track of how the days not worked are labeled or classified.

Full-time hospitalists in the group I am part of work 210 days annually. After I explain our schedule to a prospective new member of the group, I’m often asked how much vacation a new hire will get. I explain that we just specify how much work is expected of a doctor, and the non-worked days can be classified any way they would like. Understandably, some people really want a provision for vacation in the contract, so I will sometimes ask them to tell me how many vacation days they would like annually. If they say they’d like 21 days of vacation, I tell them that will be fine. We will write the contract to reflect the 231 days they are expected to work annually, but they will have 21 days of vacation. So they’re back to working the same 210 days a year that the rest of us work.

Summary

If your current contract specifies numbers of days—or weeks or hours—of vacation time and that works well, without any confusion about what constitutes a vacation day, then there is no reason to change anything right now. But you should think about what a day of vacation might mean if you change your current schedule a great deal—if you changed the duration of shifts, for example. If that might cast uncertainty on what a day of vacation means, then consider developing a contract that is silent on vacation and just specifies how much work is expected of the doctor.

I want to emphasize again that a hospitalist will have exactly the same amount of time off for vacation or any other purpose in a contract that just specifies the number of shifts/days worked and is silent on vacation time. This does not take anything away from the doctor. It is simply a different way to address the issue in the contract, while eliminating a lot of potential confusion and frustration.

If you want to know if this is really a reasonable and workable approach to vacation time, you should talk with the emergency department (ED) doctors at your hospital. If you ask them how much vacation they get, they’re likely to look puzzled and say something like, “I don’t know how much vacation time I get. All I know is that I work 14 shifts a month.” Years ago, the non-traditional working schedule used by ED doctors led many or most groups to adopt the approach to vacation I’m suggesting for hospitalists. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

The vacation conundrum most people face has to do with things like whether to drive or fly, or whether to sleep on the ground or in a hotel. But some hospitalists encounter tricky problems when figuring out how to operationalize their contractual provision for vacation time.

What is the Vacation Conundrum?

I’m a big believer in hospitalists having liberal amounts of time off, but I think most practices should avoid contractually specifying vacation time. This may sound contradictory and terribly unfair to the doctor. But avoiding a contractual guarantee of vacation time doesn’t mean the hospitalist gets any less time off. And the way hospitalist contracts address vacation time has gotten a lot of organizations in trouble. Let me explain.

Contracts often stipulate that a hospitalist will have a specified number of weeks of vacation time annually, and this language has usually been taken from the organization’s existing contracts with other physicians. But confusion often arises some time after the hospitalist practice is up and running. One big problem is deciding who will cover for the hospitalist on vacation. If all doctors work extra shifts to cover for a member of the practice who is on vacation, they will all take turns working extra—a practice that negates the effect of the promised holiday. Another problem is that most hospitalists follow non-traditional work schedules, making it difficult to determine which of the days not worked are vacation days and which are days the doctor just wasn’t scheduled to work.

To better understand this issue, it is worth thinking about how most hospitalist schedules differ from that of a typical office-based doctor or businessperson. Someone in business is usually expected to work every Monday through Friday of the year—except government holidays. Those weekdays that the business person doesn’t work are usually regarded as vacation days. (Note that I’m intentionally ignoring sick time in this discussion.) Weekend days are almost never regarded as vacation days in the business world.

But things are far more complicated for hospitalists because of the non-traditional—not always Monday through Friday—schedule they work. If a hospitalist has Tuesday and Wednesday off this week, should that be counted as vacation time or simply weekend days displaced into the middle of the week because the doctor worked the prior weekend? It is often impossible to answer this question unambiguously.

Another issue to be considered is that decisions about vacation time and the normal—non-vacation—schedule the hospitalists use are often made independently. For example, many groups use a seven days on-seven days off schedule, with 12-hour shifts on each worked day. This might lead to an agreement that every seven worked days will count as two weeks of work that has been compressed into one week on the calendar. If that’s the case, debate can arise when trying to figure out what one week of vacation really means.

One could reasonably argue that it means the doctor is relieved of five days of work, because in most jobs a week off means being off Monday through Friday. Or, because every seven worked days counts as two weeks of work, a week off could mean being relieved of half of those days—or 3.5 days off. Lastly, a hospitalist could reasonably argue that a week off means being relieved of all seven days of one of the worked weeks. This last approach is the most common way the issue is handled. Specifying vacation in numbers of days or hours, rather than in numbers of weeks, helps but does not eliminate this confusion.

Things can get really tricky when hospitalists start adjusting their standard work schedule. They might shorten or lengthen certain existing shifts or add new shifts (e.g., an evening admitting shift) all of which complicates figuring out what a day or week of vacation really means. Think about a group that has a standard schedule of 10-hour day shifts, 14-hour night shifts, and a six-hour evening admitting shift (e.g., 5 p.m. to 11 p.m.). What will a day or week of vacation mean for them? Maybe they could specify a certain number of hours of vacation rather than days or weeks. That would be useful only for practices that contract for doctors to work a specified number of hours annually, which is probably not the best way to organize a hospitalist’s work. And hours of vacation time can get pretty complicated because doctors usually don’t regard an hour of a day shift as equivalent to an hour of the night or evening shift.

I have a great relationship with a hospital executive who works a Monday-through-Friday schedule. For years, when she noticed that I had been off for a few days, she would always ask if I had just gotten back from “vacation.” I wouldn’t bother to explain to her that it usually wasn’t vacation; it was just days I wasn’t scheduled to work to make up for working 12 to 20 consecutive days. But after about a year of her asking me about my vacation every two or three weeks, she mentioned how much she envied that I had so much vacation time, when in fact I had worked more days that year—had less time off and less vacation time—than she had. I could have taken the time to respond to each of her inquiries about my vacations by explaining which were just days I wasn’t scheduled to work and which really were vacation days. But the distinction is really arbitrary. As long as I’m getting enough time off—a lot—how each of those days is labeled doesn’t really matter.

Solutions to the Vacation Conundrum

I think it’s best to use one of the following two approaches to avoid confusion about vacation time:

1. Specify how many shifts—or other work periods—the hospitalist is expected to work monthly or annually; or
2. Agree—perhaps in a contract—that each hospitalist will work the same number of days (shifts) annually unless doctors mutually decide to do otherwise.

All of the other days can be thought of as days not scheduled to work—weekends, if you will, even if the days off occur during the week instead of Saturday and Sunday—vacation days, or even CME days. That way there is no need to keep track of how the days not worked are labeled or classified.

Full-time hospitalists in the group I am part of work 210 days annually. After I explain our schedule to a prospective new member of the group, I’m often asked how much vacation a new hire will get. I explain that we just specify how much work is expected of a doctor, and the non-worked days can be classified any way they would like. Understandably, some people really want a provision for vacation in the contract, so I will sometimes ask them to tell me how many vacation days they would like annually. If they say they’d like 21 days of vacation, I tell them that will be fine. We will write the contract to reflect the 231 days they are expected to work annually, but they will have 21 days of vacation. So they’re back to working the same 210 days a year that the rest of us work.

Summary

If your current contract specifies numbers of days—or weeks or hours—of vacation time and that works well, without any confusion about what constitutes a vacation day, then there is no reason to change anything right now. But you should think about what a day of vacation might mean if you change your current schedule a great deal—if you changed the duration of shifts, for example. If that might cast uncertainty on what a day of vacation means, then consider developing a contract that is silent on vacation and just specifies how much work is expected of the doctor.

I want to emphasize again that a hospitalist will have exactly the same amount of time off for vacation or any other purpose in a contract that just specifies the number of shifts/days worked and is silent on vacation time. This does not take anything away from the doctor. It is simply a different way to address the issue in the contract, while eliminating a lot of potential confusion and frustration.

If you want to know if this is really a reasonable and workable approach to vacation time, you should talk with the emergency department (ED) doctors at your hospital. If you ask them how much vacation they get, they’re likely to look puzzled and say something like, “I don’t know how much vacation time I get. All I know is that I work 14 shifts a month.” Years ago, the non-traditional working schedule used by ED doctors led many or most groups to adopt the approach to vacation I’m suggesting for hospitalists. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

A few years ago, I cared for an unfortunate homeless patient who seemed incapable of managing his own affairs and was probably illiterate. When he left the hospital, I gave him a copy of his discharge summary and stressed that he should carry it around and always show it to anyone taking care of him. A lot went on in the hospital, and I worried he wouldn’t follow through with the subsequent care I had arranged and would instead wind up in another emergency department (ED) the next time he had a problem.

A few weeks later I got a call from another ED in the area and learned that the patient hadn’t been able to provide any meaningful details of his health history or where he had received care previously. But he did pull a wrinkled copy of the discharge summary from his pocket to show the staff. In our phone conversation, the ED doctor remarked how helpful it had been to have this information that he probably would have never found otherwise. It saved the need to pursue workup for things that I had already investigated.

I tell this story because I think it would be great for hospitalists to ensure that all, or nearly all, of their patients receive a copy of their discharge summary as they leave the hospital—or soon thereafter. In fact, I suspect that if this became common for hospitalists, the idea might become de rigueur for all patients in the hospital.

I’ve been providing a copy for many of my patients for several years. I first started doing this for patients I cared for who lived out of my area (e.g., a different state) and I couldn’t rely on the hospital getting a copy of the summary to the patient’s primary care physician (PCP) at home. That experience convinced me it could be a good idea to give it to nearly all patients.

Giving each patient a copy of selected parts of the medical record and, when requested by patients, all of the medical record, is not a new idea. I think it is great that a number of clinics and other providers mail test results to patients, and neater still are the organizations that encourage patients to “visit our Web site to review your test results” and other such information. However routinely encouraging them to review all of the test results and other records generated during a hospital stay may be an idea that isn’t yet ready for prime time. Instead, I think it is useful to give the patient a copy of the discharge summary, which highlights relevant test results with accompanying explanation and analysis.

There are many reasons this can be a good idea. Of course, a discharge summary can’t replace or reduce the need for the doctor to discuss diagnoses, treatment, and follow-up plans with the patient. Still, it is a great summary of the diagnoses, medications, and discharge instructions that the patient can review later. Research shows that many patients forget most of what they have been told by the time they get home, and my hope is that the discharge summary will serve as a reminder.

Think about the other caregivers who will see the patient after discharge. They benefit from having a discharge summary to review. Sure I’ll send a copy of the summary to the patient’s primary care doctor and to the cardiologist who consulted during the hospital stay. But what about the visiting nurse who will start seeing the patient the day after discharge? The patient can show the summary to the nurse instead of trying to recall what he was told about his illness and showing the nurse his pill bottles. Also, the patient may end up seeing doctors that I didn’t know about who won’t be getting a copy of the summary from me (my hospital). He may see other doctors in the community that he didn’t think to tell me about and can take a copy of the summary to those visits. This is why I usually tell patients to carry the summary around with them and show it to all the providers they see.

What about the patients with low health literacy? I think they might be the ones to benefit the most from getting the summary. A patient with low literacy may often get assistance from other and can show the report to these caregivers (often friends or family members). Not every patient will show the report to someone who can read it, but I think a lot of them will. So I think it’s worthwhile to give the report to everyone, just in case. If a patient is demented or otherwise incompetent, I try to get the summary into the hands of a family member or other caregiver. (Of course this can raise HIPAA-related privacy issues, and consent may be needed in some cases.)

I think that most lay people can make sense of most of what is in a discharge summary. As for the more challenging technical language in nearly every summary, sophisticated people can turn to the Internet for help. I want patients to have written reminders when they need things like a follow-up chest X-ray or results of tests that were pending at discharge. The need for specific follow-up like this gets reported directly to the PCP (via the copy of the discharge summary sent directly to him/her), and I hope that patients who have read the summary will help remind the PCP of these things.

There are two principle costs or barriers to making this standard practice. The first is that doctors tend to resist it. They worry that patients won’t understand the information or—worse—will become needlessly worried and stressed, and that the doctor will have to spend significant time “talking the patient down” from a worry that would never have arisen if the patient hadn’t been nosing around in a record that is written in “medicalese.” Or maybe the patient will read an unflattering portrayal of his situation and become angry at the doctor. (“He called me a drug seeker!”) Yet my experience shows that these are infrequent problems.

I can recall only one such incident out of the thousands of patients who have left my care with a copy of their discharge summary. One reason is that it’s now a habit for me to dictate each report while keeping in mind the idea that the patient is likely to read it. So instead of referring to a patient as a likely drug seeker, I’m apt to say something like “the patient had difficult pain management problems.” And isn’t this better language anyway? I might be wrong about his drug seeking, and any future provider who sees my report will probably still understand that drug seeking is a possibility. There are rare cases in which I think it is best not to automatically give the patient a copy of the report. These could include a proven unflattering diagnosis that the patient disputes. But remember, the patient may eventually end up seeing any report you create, so it’s worth keeping this in mind with all of your medical record documentation.

The second reason for resisting this idea is the perceived difficulty or cost of implementing it. I’m fortunate that most of my patients can get a paper copy of the discharge summary I’ve prepared as they are leaving the hospital. Of course, this requires that I dictate the report at the time of the discharge visit, and it is transcribed immediately. If you can’t pull this off, then I suggest that you have a copy mailed (or e-mailed if feasible) within a day or two of discharge. If the summary isn’t available when the patient is ready to leave, I wouldn’t have him stay and needlessly tie up a hospital bed. When this happens to my patients, I have them go ahead and leave, and a copy is mailed to them.

So I hope you will consider making this a routine practice in your hospital. The costs are small, and the potential benefit to quality of care and patient satisfaction could be significant. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

A few years ago, I cared for an unfortunate homeless patient who seemed incapable of managing his own affairs and was probably illiterate. When he left the hospital, I gave him a copy of his discharge summary and stressed that he should carry it around and always show it to anyone taking care of him. A lot went on in the hospital, and I worried he wouldn’t follow through with the subsequent care I had arranged and would instead wind up in another emergency department (ED) the next time he had a problem.

A few weeks later I got a call from another ED in the area and learned that the patient hadn’t been able to provide any meaningful details of his health history or where he had received care previously. But he did pull a wrinkled copy of the discharge summary from his pocket to show the staff. In our phone conversation, the ED doctor remarked how helpful it had been to have this information that he probably would have never found otherwise. It saved the need to pursue workup for things that I had already investigated.

I tell this story because I think it would be great for hospitalists to ensure that all, or nearly all, of their patients receive a copy of their discharge summary as they leave the hospital—or soon thereafter. In fact, I suspect that if this became common for hospitalists, the idea might become de rigueur for all patients in the hospital.

I’ve been providing a copy for many of my patients for several years. I first started doing this for patients I cared for who lived out of my area (e.g., a different state) and I couldn’t rely on the hospital getting a copy of the summary to the patient’s primary care physician (PCP) at home. That experience convinced me it could be a good idea to give it to nearly all patients.

Giving each patient a copy of selected parts of the medical record and, when requested by patients, all of the medical record, is not a new idea. I think it is great that a number of clinics and other providers mail test results to patients, and neater still are the organizations that encourage patients to “visit our Web site to review your test results” and other such information. However routinely encouraging them to review all of the test results and other records generated during a hospital stay may be an idea that isn’t yet ready for prime time. Instead, I think it is useful to give the patient a copy of the discharge summary, which highlights relevant test results with accompanying explanation and analysis.

There are many reasons this can be a good idea. Of course, a discharge summary can’t replace or reduce the need for the doctor to discuss diagnoses, treatment, and follow-up plans with the patient. Still, it is a great summary of the diagnoses, medications, and discharge instructions that the patient can review later. Research shows that many patients forget most of what they have been told by the time they get home, and my hope is that the discharge summary will serve as a reminder.

Think about the other caregivers who will see the patient after discharge. They benefit from having a discharge summary to review. Sure I’ll send a copy of the summary to the patient’s primary care doctor and to the cardiologist who consulted during the hospital stay. But what about the visiting nurse who will start seeing the patient the day after discharge? The patient can show the summary to the nurse instead of trying to recall what he was told about his illness and showing the nurse his pill bottles. Also, the patient may end up seeing doctors that I didn’t know about who won’t be getting a copy of the summary from me (my hospital). He may see other doctors in the community that he didn’t think to tell me about and can take a copy of the summary to those visits. This is why I usually tell patients to carry the summary around with them and show it to all the providers they see.

What about the patients with low health literacy? I think they might be the ones to benefit the most from getting the summary. A patient with low literacy may often get assistance from other and can show the report to these caregivers (often friends or family members). Not every patient will show the report to someone who can read it, but I think a lot of them will. So I think it’s worthwhile to give the report to everyone, just in case. If a patient is demented or otherwise incompetent, I try to get the summary into the hands of a family member or other caregiver. (Of course this can raise HIPAA-related privacy issues, and consent may be needed in some cases.)

I think that most lay people can make sense of most of what is in a discharge summary. As for the more challenging technical language in nearly every summary, sophisticated people can turn to the Internet for help. I want patients to have written reminders when they need things like a follow-up chest X-ray or results of tests that were pending at discharge. The need for specific follow-up like this gets reported directly to the PCP (via the copy of the discharge summary sent directly to him/her), and I hope that patients who have read the summary will help remind the PCP of these things.

There are two principle costs or barriers to making this standard practice. The first is that doctors tend to resist it. They worry that patients won’t understand the information or—worse—will become needlessly worried and stressed, and that the doctor will have to spend significant time “talking the patient down” from a worry that would never have arisen if the patient hadn’t been nosing around in a record that is written in “medicalese.” Or maybe the patient will read an unflattering portrayal of his situation and become angry at the doctor. (“He called me a drug seeker!”) Yet my experience shows that these are infrequent problems.

I can recall only one such incident out of the thousands of patients who have left my care with a copy of their discharge summary. One reason is that it’s now a habit for me to dictate each report while keeping in mind the idea that the patient is likely to read it. So instead of referring to a patient as a likely drug seeker, I’m apt to say something like “the patient had difficult pain management problems.” And isn’t this better language anyway? I might be wrong about his drug seeking, and any future provider who sees my report will probably still understand that drug seeking is a possibility. There are rare cases in which I think it is best not to automatically give the patient a copy of the report. These could include a proven unflattering diagnosis that the patient disputes. But remember, the patient may eventually end up seeing any report you create, so it’s worth keeping this in mind with all of your medical record documentation.

The second reason for resisting this idea is the perceived difficulty or cost of implementing it. I’m fortunate that most of my patients can get a paper copy of the discharge summary I’ve prepared as they are leaving the hospital. Of course, this requires that I dictate the report at the time of the discharge visit, and it is transcribed immediately. If you can’t pull this off, then I suggest that you have a copy mailed (or e-mailed if feasible) within a day or two of discharge. If the summary isn’t available when the patient is ready to leave, I wouldn’t have him stay and needlessly tie up a hospital bed. When this happens to my patients, I have them go ahead and leave, and a copy is mailed to them.

So I hope you will consider making this a routine practice in your hospital. The costs are small, and the potential benefit to quality of care and patient satisfaction could be significant. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

A few years ago, I cared for an unfortunate homeless patient who seemed incapable of managing his own affairs and was probably illiterate. When he left the hospital, I gave him a copy of his discharge summary and stressed that he should carry it around and always show it to anyone taking care of him. A lot went on in the hospital, and I worried he wouldn’t follow through with the subsequent care I had arranged and would instead wind up in another emergency department (ED) the next time he had a problem.

A few weeks later I got a call from another ED in the area and learned that the patient hadn’t been able to provide any meaningful details of his health history or where he had received care previously. But he did pull a wrinkled copy of the discharge summary from his pocket to show the staff. In our phone conversation, the ED doctor remarked how helpful it had been to have this information that he probably would have never found otherwise. It saved the need to pursue workup for things that I had already investigated.

I tell this story because I think it would be great for hospitalists to ensure that all, or nearly all, of their patients receive a copy of their discharge summary as they leave the hospital—or soon thereafter. In fact, I suspect that if this became common for hospitalists, the idea might become de rigueur for all patients in the hospital.

I’ve been providing a copy for many of my patients for several years. I first started doing this for patients I cared for who lived out of my area (e.g., a different state) and I couldn’t rely on the hospital getting a copy of the summary to the patient’s primary care physician (PCP) at home. That experience convinced me it could be a good idea to give it to nearly all patients.

Giving each patient a copy of selected parts of the medical record and, when requested by patients, all of the medical record, is not a new idea. I think it is great that a number of clinics and other providers mail test results to patients, and neater still are the organizations that encourage patients to “visit our Web site to review your test results” and other such information. However routinely encouraging them to review all of the test results and other records generated during a hospital stay may be an idea that isn’t yet ready for prime time. Instead, I think it is useful to give the patient a copy of the discharge summary, which highlights relevant test results with accompanying explanation and analysis.

There are many reasons this can be a good idea. Of course, a discharge summary can’t replace or reduce the need for the doctor to discuss diagnoses, treatment, and follow-up plans with the patient. Still, it is a great summary of the diagnoses, medications, and discharge instructions that the patient can review later. Research shows that many patients forget most of what they have been told by the time they get home, and my hope is that the discharge summary will serve as a reminder.

Think about the other caregivers who will see the patient after discharge. They benefit from having a discharge summary to review. Sure I’ll send a copy of the summary to the patient’s primary care doctor and to the cardiologist who consulted during the hospital stay. But what about the visiting nurse who will start seeing the patient the day after discharge? The patient can show the summary to the nurse instead of trying to recall what he was told about his illness and showing the nurse his pill bottles. Also, the patient may end up seeing doctors that I didn’t know about who won’t be getting a copy of the summary from me (my hospital). He may see other doctors in the community that he didn’t think to tell me about and can take a copy of the summary to those visits. This is why I usually tell patients to carry the summary around with them and show it to all the providers they see.

What about the patients with low health literacy? I think they might be the ones to benefit the most from getting the summary. A patient with low literacy may often get assistance from other and can show the report to these caregivers (often friends or family members). Not every patient will show the report to someone who can read it, but I think a lot of them will. So I think it’s worthwhile to give the report to everyone, just in case. If a patient is demented or otherwise incompetent, I try to get the summary into the hands of a family member or other caregiver. (Of course this can raise HIPAA-related privacy issues, and consent may be needed in some cases.)

I think that most lay people can make sense of most of what is in a discharge summary. As for the more challenging technical language in nearly every summary, sophisticated people can turn to the Internet for help. I want patients to have written reminders when they need things like a follow-up chest X-ray or results of tests that were pending at discharge. The need for specific follow-up like this gets reported directly to the PCP (via the copy of the discharge summary sent directly to him/her), and I hope that patients who have read the summary will help remind the PCP of these things.

There are two principle costs or barriers to making this standard practice. The first is that doctors tend to resist it. They worry that patients won’t understand the information or—worse—will become needlessly worried and stressed, and that the doctor will have to spend significant time “talking the patient down” from a worry that would never have arisen if the patient hadn’t been nosing around in a record that is written in “medicalese.” Or maybe the patient will read an unflattering portrayal of his situation and become angry at the doctor. (“He called me a drug seeker!”) Yet my experience shows that these are infrequent problems.

I can recall only one such incident out of the thousands of patients who have left my care with a copy of their discharge summary. One reason is that it’s now a habit for me to dictate each report while keeping in mind the idea that the patient is likely to read it. So instead of referring to a patient as a likely drug seeker, I’m apt to say something like “the patient had difficult pain management problems.” And isn’t this better language anyway? I might be wrong about his drug seeking, and any future provider who sees my report will probably still understand that drug seeking is a possibility. There are rare cases in which I think it is best not to automatically give the patient a copy of the report. These could include a proven unflattering diagnosis that the patient disputes. But remember, the patient may eventually end up seeing any report you create, so it’s worth keeping this in mind with all of your medical record documentation.

The second reason for resisting this idea is the perceived difficulty or cost of implementing it. I’m fortunate that most of my patients can get a paper copy of the discharge summary I’ve prepared as they are leaving the hospital. Of course, this requires that I dictate the report at the time of the discharge visit, and it is transcribed immediately. If you can’t pull this off, then I suggest that you have a copy mailed (or e-mailed if feasible) within a day or two of discharge. If the summary isn’t available when the patient is ready to leave, I wouldn’t have him stay and needlessly tie up a hospital bed. When this happens to my patients, I have them go ahead and leave, and a copy is mailed to them.

So I hope you will consider making this a routine practice in your hospital. The costs are small, and the potential benefit to quality of care and patient satisfaction could be significant. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

In the mid-1970s I worked as a hospital orderly. I enjoyed getting an up-close view of the hospital culture and learning a little bit about sick people. And though I didn’t realize it at the time, I was watching the early maturation of a relatively new specialty in that hospital: emergency medicine.

One day I happened to be in the emergency room (I know they call it the emergency department now) when a panic stricken dad carried in his toddler who was having an impressive tonsillar hemorrhage as a complication of a tonsillectomy done a few days earlier. The ER staff took one look at this bloody child and told the dad to carry him way across the campus to the office tower where the ENT surgeon had his office practice. I was drafted to escort the dad, still carrying the child in his arms, and left father and child in the ENT’s office thinking everything would be fine.

I’ve thought about this incident periodically since then and come to two conclusions. The first is that I was totally unaware of how seriously ill this child was until talking later with some of the doctors and nurses at the hospital. Of course I’m now a lot better at recognizing which patients are really sick, but I’ve still had situations in which I failed to appreciate the seriousness of the patient’s condition until thinking about it after the fact. My second conclusion is that this child needed emergent intervention by the ER physician, and shouldn’t have been sent across the campus to an outpatient office.

I suspect the ER doctor thought that management of this acute surgical complication was beyond the scope of his training. So he decided that the risk of delaying intervention so the child could get to the ENT’s office was less than keeping him in the ER to get IV access and start volume replacement, and so on.

Though it would sound ridiculous now, you might imagine the ER doctor defending his decision by saying “I’m not trained in the acute management of surgical complications like that.” After all, like most ER doctors of the time, his training probably consisted of a one-year rotating internship or something similar. There were no (or very few) ER residencies at the time.

But if that doctor is still practicing in an ER somewhere, I’m pretty confident he has developed the expertise required to provide the initial management of patients like this one. Like all ER doctors, and the field of emergency medicine as a whole, he needed to adjust the scope of his practice to meet the needs of the institution and healthcare system where he worked. So even if it were reasonable for him to say initial intervention for acute tonsillar hemorrhage was out of the scope of his training and expertise in the 1970s, he can’t say it anymore. Like all ER doctors, he had to seek out ways to gain training and expertise in these kinds of problems in order to respond to the needs of the institution.

I tell this story because I think we as hospitalists—and the field of hospital medicine as a whole—sometimes find ourselves in situations similar to that of the 1970s ER doctor. We are sometimes asked to provide care that might not have been part of the usual scope of practice for someone with our training. I am trained as an internist, but am sometimes asked to admit patients with problems like hip fracture or hypertensive intracerebral hemorrhage when my first impulse is that an orthopedist or a neurosurgeon should admit that patient. Or I might be asked to admit a 17-year-old and wonder if it would be better for a pediatrician to take care of that patient.

On the one hand I want to say these aren’t really internal medicine problems, so I shouldn’t be the attending for these patients (but could serve as consultant). And while that might be a reasonable position to take today, I’m convinced that I can’t dig my heels in and insist that I never become the primary admitter for these patients. I think there is too big a need for a hospitalist to care for these kinds of patients at my hospital, and it’s unreasonable for me to take a hard line and insist I will never change.

While your list of diagnoses might be different than mine, I think there is a good chance that you’re often asked to care for patients that might be a little outside the traditional scope of the specialty you trained in. Do you think that the field of hospital medicine can—or should—avoid caring for these patients long term? I don’t. I think we need to gradually take on some of the new roles that our hospitals and physician colleagues request of us. Just like the ER doctors of the 1970s, I think we are in a period of significant evolution as our field “grows up.” And rather than resisting this change, I think we should thoughtfully decide where “the system” needs our services the most and work to develop the expertise to meet that need.

Some hospitalists are really uncomfortable with the idea of expanding the scope of their practice and raise a number of objections. They sometimes say “That’s fine if Nelson wants to care for patients with head bleeds, but there is no way I’m going to do it since it’s a sure path to a law suit.” Or “I’m happy to consult and manage the blood pressure, but there’s no way I’m willing to be attending.”

But don’t doctors in most specialties adjust their scope of practice regularly? Think about surgeons who have had to learn laparoscopic techniques after their residency training. And office-based internists who had little outpatient training during residency but have had to learn to be expert at it once they started practice. They are adapting the scope of their practice to the needs of the healthcare system, and they’ve found ways to gain competence and expertise in these areas.

I’m not suggesting we admit any type of patient someone might want us to. Nor am I confident that the two important areas for hospital medicine to become more involved in are hip fracture and hypertensive intracerebral hemorrhage (though they do seem to come up regularly). My point is that I don’t think we can dig our heels in and resist any change in our scope of practice. In our own local practices, and as a specialty, we need to decide the most valuable ways to adjust our practice scope and work diligently to become competent at them. We will still need an orthopedist to operate on the hip and a neurosurgeon to see patients with “head bleeds,” but maybe the system really needs, and could benefit from, hospitalists who have an increased role in caring for these patients. As our field evolves, training programs and CME courses will adapt to meet our need for more training in these areas that may feel new or unfamiliar to many of us.

Some days after the child with tonsillar hemorrhage presented, I learned that he had done OK and had gone home looking good. But the surgeon was furious that we had “dumped” this patient at his door without any warning and had sent the patient into his waiting room where other waiting patients were apparently horrified. The ER doctor could have responded that the surgeon should quit complaining and get used to this kind of thing because “it comes with the turf” of ENT practice. Or he could have told the ENT doctor he’d like for the two of them to work together to develop a way for the ER to play a much bigger role in the early emergent intervention.

I hope that when we find ourselves in a similar situation we try the latter response. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

In the mid-1970s I worked as a hospital orderly. I enjoyed getting an up-close view of the hospital culture and learning a little bit about sick people. And though I didn’t realize it at the time, I was watching the early maturation of a relatively new specialty in that hospital: emergency medicine.

One day I happened to be in the emergency room (I know they call it the emergency department now) when a panic stricken dad carried in his toddler who was having an impressive tonsillar hemorrhage as a complication of a tonsillectomy done a few days earlier. The ER staff took one look at this bloody child and told the dad to carry him way across the campus to the office tower where the ENT surgeon had his office practice. I was drafted to escort the dad, still carrying the child in his arms, and left father and child in the ENT’s office thinking everything would be fine.

I’ve thought about this incident periodically since then and come to two conclusions. The first is that I was totally unaware of how seriously ill this child was until talking later with some of the doctors and nurses at the hospital. Of course I’m now a lot better at recognizing which patients are really sick, but I’ve still had situations in which I failed to appreciate the seriousness of the patient’s condition until thinking about it after the fact. My second conclusion is that this child needed emergent intervention by the ER physician, and shouldn’t have been sent across the campus to an outpatient office.

I suspect the ER doctor thought that management of this acute surgical complication was beyond the scope of his training. So he decided that the risk of delaying intervention so the child could get to the ENT’s office was less than keeping him in the ER to get IV access and start volume replacement, and so on.

Though it would sound ridiculous now, you might imagine the ER doctor defending his decision by saying “I’m not trained in the acute management of surgical complications like that.” After all, like most ER doctors of the time, his training probably consisted of a one-year rotating internship or something similar. There were no (or very few) ER residencies at the time.

But if that doctor is still practicing in an ER somewhere, I’m pretty confident he has developed the expertise required to provide the initial management of patients like this one. Like all ER doctors, and the field of emergency medicine as a whole, he needed to adjust the scope of his practice to meet the needs of the institution and healthcare system where he worked. So even if it were reasonable for him to say initial intervention for acute tonsillar hemorrhage was out of the scope of his training and expertise in the 1970s, he can’t say it anymore. Like all ER doctors, he had to seek out ways to gain training and expertise in these kinds of problems in order to respond to the needs of the institution.

I tell this story because I think we as hospitalists—and the field of hospital medicine as a whole—sometimes find ourselves in situations similar to that of the 1970s ER doctor. We are sometimes asked to provide care that might not have been part of the usual scope of practice for someone with our training. I am trained as an internist, but am sometimes asked to admit patients with problems like hip fracture or hypertensive intracerebral hemorrhage when my first impulse is that an orthopedist or a neurosurgeon should admit that patient. Or I might be asked to admit a 17-year-old and wonder if it would be better for a pediatrician to take care of that patient.

On the one hand I want to say these aren’t really internal medicine problems, so I shouldn’t be the attending for these patients (but could serve as consultant). And while that might be a reasonable position to take today, I’m convinced that I can’t dig my heels in and insist that I never become the primary admitter for these patients. I think there is too big a need for a hospitalist to care for these kinds of patients at my hospital, and it’s unreasonable for me to take a hard line and insist I will never change.

While your list of diagnoses might be different than mine, I think there is a good chance that you’re often asked to care for patients that might be a little outside the traditional scope of the specialty you trained in. Do you think that the field of hospital medicine can—or should—avoid caring for these patients long term? I don’t. I think we need to gradually take on some of the new roles that our hospitals and physician colleagues request of us. Just like the ER doctors of the 1970s, I think we are in a period of significant evolution as our field “grows up.” And rather than resisting this change, I think we should thoughtfully decide where “the system” needs our services the most and work to develop the expertise to meet that need.

Some hospitalists are really uncomfortable with the idea of expanding the scope of their practice and raise a number of objections. They sometimes say “That’s fine if Nelson wants to care for patients with head bleeds, but there is no way I’m going to do it since it’s a sure path to a law suit.” Or “I’m happy to consult and manage the blood pressure, but there’s no way I’m willing to be attending.”

But don’t doctors in most specialties adjust their scope of practice regularly? Think about surgeons who have had to learn laparoscopic techniques after their residency training. And office-based internists who had little outpatient training during residency but have had to learn to be expert at it once they started practice. They are adapting the scope of their practice to the needs of the healthcare system, and they’ve found ways to gain competence and expertise in these areas.

I’m not suggesting we admit any type of patient someone might want us to. Nor am I confident that the two important areas for hospital medicine to become more involved in are hip fracture and hypertensive intracerebral hemorrhage (though they do seem to come up regularly). My point is that I don’t think we can dig our heels in and resist any change in our scope of practice. In our own local practices, and as a specialty, we need to decide the most valuable ways to adjust our practice scope and work diligently to become competent at them. We will still need an orthopedist to operate on the hip and a neurosurgeon to see patients with “head bleeds,” but maybe the system really needs, and could benefit from, hospitalists who have an increased role in caring for these patients. As our field evolves, training programs and CME courses will adapt to meet our need for more training in these areas that may feel new or unfamiliar to many of us.

Some days after the child with tonsillar hemorrhage presented, I learned that he had done OK and had gone home looking good. But the surgeon was furious that we had “dumped” this patient at his door without any warning and had sent the patient into his waiting room where other waiting patients were apparently horrified. The ER doctor could have responded that the surgeon should quit complaining and get used to this kind of thing because “it comes with the turf” of ENT practice. Or he could have told the ENT doctor he’d like for the two of them to work together to develop a way for the ER to play a much bigger role in the early emergent intervention.

I hope that when we find ourselves in a similar situation we try the latter response. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

In the mid-1970s I worked as a hospital orderly. I enjoyed getting an up-close view of the hospital culture and learning a little bit about sick people. And though I didn’t realize it at the time, I was watching the early maturation of a relatively new specialty in that hospital: emergency medicine.

One day I happened to be in the emergency room (I know they call it the emergency department now) when a panic stricken dad carried in his toddler who was having an impressive tonsillar hemorrhage as a complication of a tonsillectomy done a few days earlier. The ER staff took one look at this bloody child and told the dad to carry him way across the campus to the office tower where the ENT surgeon had his office practice. I was drafted to escort the dad, still carrying the child in his arms, and left father and child in the ENT’s office thinking everything would be fine.

I’ve thought about this incident periodically since then and come to two conclusions. The first is that I was totally unaware of how seriously ill this child was until talking later with some of the doctors and nurses at the hospital. Of course I’m now a lot better at recognizing which patients are really sick, but I’ve still had situations in which I failed to appreciate the seriousness of the patient’s condition until thinking about it after the fact. My second conclusion is that this child needed emergent intervention by the ER physician, and shouldn’t have been sent across the campus to an outpatient office.

I suspect the ER doctor thought that management of this acute surgical complication was beyond the scope of his training. So he decided that the risk of delaying intervention so the child could get to the ENT’s office was less than keeping him in the ER to get IV access and start volume replacement, and so on.

Though it would sound ridiculous now, you might imagine the ER doctor defending his decision by saying “I’m not trained in the acute management of surgical complications like that.” After all, like most ER doctors of the time, his training probably consisted of a one-year rotating internship or something similar. There were no (or very few) ER residencies at the time.

But if that doctor is still practicing in an ER somewhere, I’m pretty confident he has developed the expertise required to provide the initial management of patients like this one. Like all ER doctors, and the field of emergency medicine as a whole, he needed to adjust the scope of his practice to meet the needs of the institution and healthcare system where he worked. So even if it were reasonable for him to say initial intervention for acute tonsillar hemorrhage was out of the scope of his training and expertise in the 1970s, he can’t say it anymore. Like all ER doctors, he had to seek out ways to gain training and expertise in these kinds of problems in order to respond to the needs of the institution.

I tell this story because I think we as hospitalists—and the field of hospital medicine as a whole—sometimes find ourselves in situations similar to that of the 1970s ER doctor. We are sometimes asked to provide care that might not have been part of the usual scope of practice for someone with our training. I am trained as an internist, but am sometimes asked to admit patients with problems like hip fracture or hypertensive intracerebral hemorrhage when my first impulse is that an orthopedist or a neurosurgeon should admit that patient. Or I might be asked to admit a 17-year-old and wonder if it would be better for a pediatrician to take care of that patient.

On the one hand I want to say these aren’t really internal medicine problems, so I shouldn’t be the attending for these patients (but could serve as consultant). And while that might be a reasonable position to take today, I’m convinced that I can’t dig my heels in and insist that I never become the primary admitter for these patients. I think there is too big a need for a hospitalist to care for these kinds of patients at my hospital, and it’s unreasonable for me to take a hard line and insist I will never change.

While your list of diagnoses might be different than mine, I think there is a good chance that you’re often asked to care for patients that might be a little outside the traditional scope of the specialty you trained in. Do you think that the field of hospital medicine can—or should—avoid caring for these patients long term? I don’t. I think we need to gradually take on some of the new roles that our hospitals and physician colleagues request of us. Just like the ER doctors of the 1970s, I think we are in a period of significant evolution as our field “grows up.” And rather than resisting this change, I think we should thoughtfully decide where “the system” needs our services the most and work to develop the expertise to meet that need.

Some hospitalists are really uncomfortable with the idea of expanding the scope of their practice and raise a number of objections. They sometimes say “That’s fine if Nelson wants to care for patients with head bleeds, but there is no way I’m going to do it since it’s a sure path to a law suit.” Or “I’m happy to consult and manage the blood pressure, but there’s no way I’m willing to be attending.”

But don’t doctors in most specialties adjust their scope of practice regularly? Think about surgeons who have had to learn laparoscopic techniques after their residency training. And office-based internists who had little outpatient training during residency but have had to learn to be expert at it once they started practice. They are adapting the scope of their practice to the needs of the healthcare system, and they’ve found ways to gain competence and expertise in these areas.

I’m not suggesting we admit any type of patient someone might want us to. Nor am I confident that the two important areas for hospital medicine to become more involved in are hip fracture and hypertensive intracerebral hemorrhage (though they do seem to come up regularly). My point is that I don’t think we can dig our heels in and resist any change in our scope of practice. In our own local practices, and as a specialty, we need to decide the most valuable ways to adjust our practice scope and work diligently to become competent at them. We will still need an orthopedist to operate on the hip and a neurosurgeon to see patients with “head bleeds,” but maybe the system really needs, and could benefit from, hospitalists who have an increased role in caring for these patients. As our field evolves, training programs and CME courses will adapt to meet our need for more training in these areas that may feel new or unfamiliar to many of us.

Some days after the child with tonsillar hemorrhage presented, I learned that he had done OK and had gone home looking good. But the surgeon was furious that we had “dumped” this patient at his door without any warning and had sent the patient into his waiting room where other waiting patients were apparently horrified. The ER doctor could have responded that the surgeon should quit complaining and get used to this kind of thing because “it comes with the turf” of ENT practice. Or he could have told the ENT doctor he’d like for the two of them to work together to develop a way for the ER to play a much bigger role in the early emergent intervention.

I hope that when we find ourselves in a similar situation we try the latter response. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Editors’ note: This month we begin a new bimonthly column authored by John Nelson, MD. Dr. Nelson will cover practical, real-life topics and ideas for improving your practice in this space during the coming months.

Are you pretty sure your workload is in the sweet spot? That is, do you think you’re seeing the “right” number of patients? For most of us this isn’t an easy question to answer. My wife figured this out a long time ago. When she asked me “So how was it today?” at the end of the work day, I would nearly always answer “Too busy” or “Too slow.” On the rare occasion I enthusiastically said the day’s workload was “just right” she would nearly fall out of her chair. (Disclosure: Now the way I really answer her question most often is to say, “It was OK. How was your day?” I learned that the constant too busy/too slow answers are a downer and marital accord is served by other responses. I share this hoping you can benefit from my experience, but marital advice isn’t the point of this column.)

How you feel about your workload from day to day is terribly significant, but just how do you decide what the right workload is? More importantly, what can be done if you’re convinced you’re constantly working too hard or at an unsustainable pace?

This month I’ll offer thoughts for those who feel they’re seeing too many patients. In future installments of “Practice Management,” I’ll address those seemingly rare people who think their patient volume is too low.

Comparing Apples with Apples

If you think you’re seeing too many patients, you probably want to know the typical patient volume for hospitalists in practices similar to yours. So it is natural to turn to survey data, such as the SHM Compensation and Productivity Survey, which is published about every two years (results of the 2005-2006 are available to SHM members at www.hospitalmedicine.org).

You might think about how your practice differs from the average practice in the survey to explain why your volume should be higher or lower. Then you might talk with individual hospitalists from other practices, and even the colleagues in your own practice. What is their patient volume and do they think it is too high, too low, or the elusive just right?

So by comparing your workload with external benchmarks, you know the real answer to whether your patient volume is too high or not. Right? Not so fast. Who says you are average and should feel comfortable working at the average pace? Isn’t it possible that the right patient volume for you is different than for others? I think data from other hospitalists serve only as a rough guideline and starting point for deciding about your own volume. Ideally you should have significant latitude to decide where the sweet spot is for yourself. Kudos if you’re in that situation now.

Unfortunately, instead of having a lot of latitude to decide for themselves, many hospitalists complain that their hospital executive/employer insists that they see at least X wRVUs/visits/new encounters (where X is usually heavily influenced by the SHM survey or other database). And it is especially frustrating to have an executive who doesn’t know what it is like to work as a hospitalist decide about the right workload for you.

If you are in a practice where you have little say about how many patients you see, here is a strategy to secure a much greater degree of control over this decision: Offer to decide for yourself and accept the change in your salary that will occur as a result of your patient volume changes. For this to work you will need to have a compensation scheme that has a connection between your production and your income. (Details of such a salary are beyond the scope of this column, but let me assure you it isn’t as complicated or risky as you might fear.)

Case in Point

Let me briefly illustrate with a hypothetical example from an outpatient primary care practice. Doctor A opens a solo office and decides to work 4.5 days a week and see 22 patients each day (11 on the half day). He’s chosen this workload because it seems reasonable, safe for patient care, and rewards him with what he regards as a reasonable salary. In other words, he feels like he has found the sweet spot for workload and income (productivity and compensation).

Dr. A then recruits a partner, Doctor B, whom he pays the same salary as himself and tells Dr. B he must work 4.5 days a week and see the same patient volume as he does. Dr. B is able to conform to this, but isn’t so sure he’s working in his own productivity and compensation sweet spot. Over the next few years the group grows to 10 doctors, all making the same salary, working 4.5 days a week, and seeing the same number of patients each day.

Are all 10 doctors in this practice likely to be happy with their workload? I don’t think so. I’d recommend they look for a way to let each individual doctor decide independently (within some broad boundaries) to work different amounts, varying the number of days worked, or daily patient workload.

A single parent might work only three days a week when childcare is available; an energetic doctor might decide to work five full days a week, and so on. In fact, this is how most private primary care practices operate. And they do this despite complicated decisions about how to allocate overhead between doctors with different levels of productivity, an issue that is usually much less difficult for hospitalists than primary care offices.

But a significant number of hospitalists are in a practice that looks like Dr. A’s. They’re hired at a predetermined salary and then are urged, or required, to see a specified number of patients and work a specified number of days or shifts. A great deal of effort often goes into getting each doctor to handle a workload that is similar to others in the practice. This patient volume/workload target is usually vague until the hospitalists want to add a new doctor and the employer must be convinced the doctors are working very hard. At this point the SHM survey data and other tools often come into play, and patient volume expectations become much clearer through what is often a somewhat unpleasant negotiation.

So if you’re in a situation where a hospital executive or other employer decides the appropriate patient volume for you, think about changing to a compensation system that enables you to decide for yourself the sweet spot between patient volume, days or shifts worked (time off), and income. Most employers—especially hospital executives—are delighted to switch to production-based compensation and let you decide for yourself how many patients you see.

Switching to a salary based significantly—or entirely—on production often raises a number of questions that, again, I’ll address in a future column. But my point here is that it can be quite liberating because it lets you make your own decisions about productivity. It might be the thing that allows each member of your group to decide, within some generous boundaries, just how hard he or she wants to work. And the group as a whole can decide more independently when additional doctors should be added.

I encourage each group to operate in a way that maximizes individual doctors’ ability to decide where the patient volume sweet spot is—whether through a production-based salary or other methods. Don’t let this decision be based too heavily on things such as survey data and the decisions of hospital executives.

Closing Thoughts

My goal in writing this column is to stimulate your thinking about your own practice—not to provide a prescription for the one right way to operate a practice. After all, the best way to operate a practice varies from one place to the next.

I plan to address controversial topics regularly, hoping to achieve two objectives. The first is that some of my ramblings help you think about the best way to operate your own practice. The second is that some of you might decide to e-mail us (at ldionne@wiley.com) your point of view—some of which can be printed here so that we can learn from each other about the options for operating a successful practice. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Editors’ note: This month we begin a new bimonthly column authored by John Nelson, MD. Dr. Nelson will cover practical, real-life topics and ideas for improving your practice in this space during the coming months.

Are you pretty sure your workload is in the sweet spot? That is, do you think you’re seeing the “right” number of patients? For most of us this isn’t an easy question to answer. My wife figured this out a long time ago. When she asked me “So how was it today?” at the end of the work day, I would nearly always answer “Too busy” or “Too slow.” On the rare occasion I enthusiastically said the day’s workload was “just right” she would nearly fall out of her chair. (Disclosure: Now the way I really answer her question most often is to say, “It was OK. How was your day?” I learned that the constant too busy/too slow answers are a downer and marital accord is served by other responses. I share this hoping you can benefit from my experience, but marital advice isn’t the point of this column.)

How you feel about your workload from day to day is terribly significant, but just how do you decide what the right workload is? More importantly, what can be done if you’re convinced you’re constantly working too hard or at an unsustainable pace?

This month I’ll offer thoughts for those who feel they’re seeing too many patients. In future installments of “Practice Management,” I’ll address those seemingly rare people who think their patient volume is too low.

Comparing Apples with Apples

If you think you’re seeing too many patients, you probably want to know the typical patient volume for hospitalists in practices similar to yours. So it is natural to turn to survey data, such as the SHM Compensation and Productivity Survey, which is published about every two years (results of the 2005-2006 are available to SHM members at www.hospitalmedicine.org).

You might think about how your practice differs from the average practice in the survey to explain why your volume should be higher or lower. Then you might talk with individual hospitalists from other practices, and even the colleagues in your own practice. What is their patient volume and do they think it is too high, too low, or the elusive just right?

So by comparing your workload with external benchmarks, you know the real answer to whether your patient volume is too high or not. Right? Not so fast. Who says you are average and should feel comfortable working at the average pace? Isn’t it possible that the right patient volume for you is different than for others? I think data from other hospitalists serve only as a rough guideline and starting point for deciding about your own volume. Ideally you should have significant latitude to decide where the sweet spot is for yourself. Kudos if you’re in that situation now.

Unfortunately, instead of having a lot of latitude to decide for themselves, many hospitalists complain that their hospital executive/employer insists that they see at least X wRVUs/visits/new encounters (where X is usually heavily influenced by the SHM survey or other database). And it is especially frustrating to have an executive who doesn’t know what it is like to work as a hospitalist decide about the right workload for you.

If you are in a practice where you have little say about how many patients you see, here is a strategy to secure a much greater degree of control over this decision: Offer to decide for yourself and accept the change in your salary that will occur as a result of your patient volume changes. For this to work you will need to have a compensation scheme that has a connection between your production and your income. (Details of such a salary are beyond the scope of this column, but let me assure you it isn’t as complicated or risky as you might fear.)

Case in Point

Let me briefly illustrate with a hypothetical example from an outpatient primary care practice. Doctor A opens a solo office and decides to work 4.5 days a week and see 22 patients each day (11 on the half day). He’s chosen this workload because it seems reasonable, safe for patient care, and rewards him with what he regards as a reasonable salary. In other words, he feels like he has found the sweet spot for workload and income (productivity and compensation).

Dr. A then recruits a partner, Doctor B, whom he pays the same salary as himself and tells Dr. B he must work 4.5 days a week and see the same patient volume as he does. Dr. B is able to conform to this, but isn’t so sure he’s working in his own productivity and compensation sweet spot. Over the next few years the group grows to 10 doctors, all making the same salary, working 4.5 days a week, and seeing the same number of patients each day.

Are all 10 doctors in this practice likely to be happy with their workload? I don’t think so. I’d recommend they look for a way to let each individual doctor decide independently (within some broad boundaries) to work different amounts, varying the number of days worked, or daily patient workload.

A single parent might work only three days a week when childcare is available; an energetic doctor might decide to work five full days a week, and so on. In fact, this is how most private primary care practices operate. And they do this despite complicated decisions about how to allocate overhead between doctors with different levels of productivity, an issue that is usually much less difficult for hospitalists than primary care offices.

But a significant number of hospitalists are in a practice that looks like Dr. A’s. They’re hired at a predetermined salary and then are urged, or required, to see a specified number of patients and work a specified number of days or shifts. A great deal of effort often goes into getting each doctor to handle a workload that is similar to others in the practice. This patient volume/workload target is usually vague until the hospitalists want to add a new doctor and the employer must be convinced the doctors are working very hard. At this point the SHM survey data and other tools often come into play, and patient volume expectations become much clearer through what is often a somewhat unpleasant negotiation.

So if you’re in a situation where a hospital executive or other employer decides the appropriate patient volume for you, think about changing to a compensation system that enables you to decide for yourself the sweet spot between patient volume, days or shifts worked (time off), and income. Most employers—especially hospital executives—are delighted to switch to production-based compensation and let you decide for yourself how many patients you see.

Switching to a salary based significantly—or entirely—on production often raises a number of questions that, again, I’ll address in a future column. But my point here is that it can be quite liberating because it lets you make your own decisions about productivity. It might be the thing that allows each member of your group to decide, within some generous boundaries, just how hard he or she wants to work. And the group as a whole can decide more independently when additional doctors should be added.

I encourage each group to operate in a way that maximizes individual doctors’ ability to decide where the patient volume sweet spot is—whether through a production-based salary or other methods. Don’t let this decision be based too heavily on things such as survey data and the decisions of hospital executives.

Closing Thoughts

My goal in writing this column is to stimulate your thinking about your own practice—not to provide a prescription for the one right way to operate a practice. After all, the best way to operate a practice varies from one place to the next.

I plan to address controversial topics regularly, hoping to achieve two objectives. The first is that some of my ramblings help you think about the best way to operate your own practice. The second is that some of you might decide to e-mail us (at ldionne@wiley.com) your point of view—some of which can be printed here so that we can learn from each other about the options for operating a successful practice. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Editors’ note: This month we begin a new bimonthly column authored by John Nelson, MD. Dr. Nelson will cover practical, real-life topics and ideas for improving your practice in this space during the coming months.

Are you pretty sure your workload is in the sweet spot? That is, do you think you’re seeing the “right” number of patients? For most of us this isn’t an easy question to answer. My wife figured this out a long time ago. When she asked me “So how was it today?” at the end of the work day, I would nearly always answer “Too busy” or “Too slow.” On the rare occasion I enthusiastically said the day’s workload was “just right” she would nearly fall out of her chair. (Disclosure: Now the way I really answer her question most often is to say, “It was OK. How was your day?” I learned that the constant too busy/too slow answers are a downer and marital accord is served by other responses. I share this hoping you can benefit from my experience, but marital advice isn’t the point of this column.)

How you feel about your workload from day to day is terribly significant, but just how do you decide what the right workload is? More importantly, what can be done if you’re convinced you’re constantly working too hard or at an unsustainable pace?

This month I’ll offer thoughts for those who feel they’re seeing too many patients. In future installments of “Practice Management,” I’ll address those seemingly rare people who think their patient volume is too low.

Comparing Apples with Apples

If you think you’re seeing too many patients, you probably want to know the typical patient volume for hospitalists in practices similar to yours. So it is natural to turn to survey data, such as the SHM Compensation and Productivity Survey, which is published about every two years (results of the 2005-2006 are available to SHM members at www.hospitalmedicine.org).

You might think about how your practice differs from the average practice in the survey to explain why your volume should be higher or lower. Then you might talk with individual hospitalists from other practices, and even the colleagues in your own practice. What is their patient volume and do they think it is too high, too low, or the elusive just right?

So by comparing your workload with external benchmarks, you know the real answer to whether your patient volume is too high or not. Right? Not so fast. Who says you are average and should feel comfortable working at the average pace? Isn’t it possible that the right patient volume for you is different than for others? I think data from other hospitalists serve only as a rough guideline and starting point for deciding about your own volume. Ideally you should have significant latitude to decide where the sweet spot is for yourself. Kudos if you’re in that situation now.

Unfortunately, instead of having a lot of latitude to decide for themselves, many hospitalists complain that their hospital executive/employer insists that they see at least X wRVUs/visits/new encounters (where X is usually heavily influenced by the SHM survey or other database). And it is especially frustrating to have an executive who doesn’t know what it is like to work as a hospitalist decide about the right workload for you.

If you are in a practice where you have little say about how many patients you see, here is a strategy to secure a much greater degree of control over this decision: Offer to decide for yourself and accept the change in your salary that will occur as a result of your patient volume changes. For this to work you will need to have a compensation scheme that has a connection between your production and your income. (Details of such a salary are beyond the scope of this column, but let me assure you it isn’t as complicated or risky as you might fear.)

Case in Point

Let me briefly illustrate with a hypothetical example from an outpatient primary care practice. Doctor A opens a solo office and decides to work 4.5 days a week and see 22 patients each day (11 on the half day). He’s chosen this workload because it seems reasonable, safe for patient care, and rewards him with what he regards as a reasonable salary. In other words, he feels like he has found the sweet spot for workload and income (productivity and compensation).

Dr. A then recruits a partner, Doctor B, whom he pays the same salary as himself and tells Dr. B he must work 4.5 days a week and see the same patient volume as he does. Dr. B is able to conform to this, but isn’t so sure he’s working in his own productivity and compensation sweet spot. Over the next few years the group grows to 10 doctors, all making the same salary, working 4.5 days a week, and seeing the same number of patients each day.

Are all 10 doctors in this practice likely to be happy with their workload? I don’t think so. I’d recommend they look for a way to let each individual doctor decide independently (within some broad boundaries) to work different amounts, varying the number of days worked, or daily patient workload.

A single parent might work only three days a week when childcare is available; an energetic doctor might decide to work five full days a week, and so on. In fact, this is how most private primary care practices operate. And they do this despite complicated decisions about how to allocate overhead between doctors with different levels of productivity, an issue that is usually much less difficult for hospitalists than primary care offices.

But a significant number of hospitalists are in a practice that looks like Dr. A’s. They’re hired at a predetermined salary and then are urged, or required, to see a specified number of patients and work a specified number of days or shifts. A great deal of effort often goes into getting each doctor to handle a workload that is similar to others in the practice. This patient volume/workload target is usually vague until the hospitalists want to add a new doctor and the employer must be convinced the doctors are working very hard. At this point the SHM survey data and other tools often come into play, and patient volume expectations become much clearer through what is often a somewhat unpleasant negotiation.

So if you’re in a situation where a hospital executive or other employer decides the appropriate patient volume for you, think about changing to a compensation system that enables you to decide for yourself the sweet spot between patient volume, days or shifts worked (time off), and income. Most employers—especially hospital executives—are delighted to switch to production-based compensation and let you decide for yourself how many patients you see.

Switching to a salary based significantly—or entirely—on production often raises a number of questions that, again, I’ll address in a future column. But my point here is that it can be quite liberating because it lets you make your own decisions about productivity. It might be the thing that allows each member of your group to decide, within some generous boundaries, just how hard he or she wants to work. And the group as a whole can decide more independently when additional doctors should be added.

I encourage each group to operate in a way that maximizes individual doctors’ ability to decide where the patient volume sweet spot is—whether through a production-based salary or other methods. Don’t let this decision be based too heavily on things such as survey data and the decisions of hospital executives.

Closing Thoughts

My goal in writing this column is to stimulate your thinking about your own practice—not to provide a prescription for the one right way to operate a practice. After all, the best way to operate a practice varies from one place to the next.

I plan to address controversial topics regularly, hoping to achieve two objectives. The first is that some of my ramblings help you think about the best way to operate your own practice. The second is that some of you might decide to e-mail us (at ldionne@wiley.com) your point of view—some of which can be printed here so that we can learn from each other about the options for operating a successful practice. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.