Joseph Ming-Wah Li, MD, MPH, SFHM

Who are you?

I am a 44-year-old Chinese-American male who works as a hospitalist at Beth Israel Deaconess Medical Center (BIDMC), an academic medical center in Boston. BIDMC is affiliated with Harvard Medical School, where I am an associate professor of medicine.

If you are about to join or renew your SHM membership, you can expect SHM to ask some questions it’s never asked before. What is your gender? What is your age? What is your ethnicity? I would not be surprised if you wondered why SHM is asking these questions. What does it have to do with my membership? Why are they asking now when they never asked before? I do not remember other professional medical societies asking these types of questions—should I be concerned? Is this an unnecessary invasion of privacy?

Call to Action

Nearly two years ago, when I had the good fortune of being elected SHM’s president-elect, I asked, What do we know about SHM members? As it turns out, it’s less than I thought we knew.

SHM has been in the survey business for years. The most visible survey is the annual productivity and compensation survey (see “Survey Insights,” p. TK). The data from this instrument have become very important, thanks to the many of you who have participated. In the early years of hospital medicine, everyone wanted to know how hard others were working and how much others were getting paid. If others had a better compensation package, it was the proof one needed to go marching into the C-suite asking for more support. If others were making less, it was the competitive advantage one needed to land the next hot-prospect hospitalist.

To be fair, I remember the surveys also asked about hospitalist age and employment model. But I don’t remember any questions about gender, race, or other personal information. The survey was the productivity and compensation survey, so maybe it had nothing to do with gender and race … but maybe it should.

Diverse, Yet Not So Much

Over the years, when I’ve walked the hallways at the SHM annual meeting, I got the sense that it was a reasonably diverse crowd. Take a look when you are at the San Diego Convention Center in April, and I expect you will agree. I grant you that it is generally a younger crowd than what one would find at most medical meetings, but I see people of many ethnic backgrounds, and there are equal parts women and men.

What was striking to me, however, was when I walked into some of the smaller conference rooms where the SHM committee meetings were being held and where the leaders sat. That crowd didn’t seem nearly as diverse as the crowd in the bigger rooms. I remember asking one of my colleagues whether he had the same perception. He told me he didn’t see it that way. Then again, it dawned on me that he is white and works at an academic medical center. What if he walked into leadership committee meetings filled with women from under-represented minority groups who work in community hospitals? My guess is that he would notice right away.

But my perception is biased, so when I became SHM president last spring, I asked that we assemble some facts about our members. SHM pulled together a task force, which developed a survey and took a snapshot of SHM membership. Some of you may have received this survey; it was sent out to thousands of SHM members.

The survey results, which were shared recently with SHM’s board of directors, confirmed my suspicions: SHM membership is a reasonably diverse crowd when it comes to gender and race. When it came to the SHM committee membership, I was right and wrong. The percentage of women and under-represented minorities on SHM committees reflected overall SHM membership reasonably well, but it was clear that fewer women and under-represented minorities held senior leadership positions, such as committee chairs and positions on the board. I suspect this is no different at other professional medical societies and more of a commentary on medicine than on SHM.

The most striking difference, however, did not have to do with race or gender, but instead had to do with employment model. Hospitalists who work at places other than academic medical centers are clearly under-represented in SHM leadership positions.

Action Item: New Knowledge, Better Understanding

So what do we do with this information? Am I suggesting that we set aside special seats at the board table for specific types of people or special-interest groups, some seats just for women, and some just for hospitalists who work in community hospitals? I am not advocating any such action.

I did ask SHM leadership to initiate action to help us continually understand the makeup of SHM membership and compare it to representation at the leadership level. SHM leadership overwhelmingly agreed. This is the reason you are being asked to volunteer personal information when you renew your membership.

It is my hope and belief that SHM will use this information appropriately when they organize committees and build leadership teams. This information, if used appropriately, will help SHM leadership understand its potential bias and guard against unintended consequences of their actions.

I recognize that some people will argue that the questions being asked are not sufficiently comprehensive. We should also be asking about other individual characteristics. You may or may not be right, but at this time, I think we are taking a step in the right direction. Further steps may be forthcoming in the future, but let’s not let perfection be the enemy of good.

If you have any comments about this article, please contact me at JosephLi@HospitalMedicine.org. I’m also available on LinkedIn (JosephLi) and Twitter (@_JosephLi).

Dr. Li is president of SHM.

Who are you?

I am a 44-year-old Chinese-American male who works as a hospitalist at Beth Israel Deaconess Medical Center (BIDMC), an academic medical center in Boston. BIDMC is affiliated with Harvard Medical School, where I am an associate professor of medicine.

If you are about to join or renew your SHM membership, you can expect SHM to ask some questions it’s never asked before. What is your gender? What is your age? What is your ethnicity? I would not be surprised if you wondered why SHM is asking these questions. What does it have to do with my membership? Why are they asking now when they never asked before? I do not remember other professional medical societies asking these types of questions—should I be concerned? Is this an unnecessary invasion of privacy?

Call to Action

Nearly two years ago, when I had the good fortune of being elected SHM’s president-elect, I asked, What do we know about SHM members? As it turns out, it’s less than I thought we knew.

SHM has been in the survey business for years. The most visible survey is the annual productivity and compensation survey (see “Survey Insights,” p. TK). The data from this instrument have become very important, thanks to the many of you who have participated. In the early years of hospital medicine, everyone wanted to know how hard others were working and how much others were getting paid. If others had a better compensation package, it was the proof one needed to go marching into the C-suite asking for more support. If others were making less, it was the competitive advantage one needed to land the next hot-prospect hospitalist.

To be fair, I remember the surveys also asked about hospitalist age and employment model. But I don’t remember any questions about gender, race, or other personal information. The survey was the productivity and compensation survey, so maybe it had nothing to do with gender and race … but maybe it should.

Diverse, Yet Not So Much

Over the years, when I’ve walked the hallways at the SHM annual meeting, I got the sense that it was a reasonably diverse crowd. Take a look when you are at the San Diego Convention Center in April, and I expect you will agree. I grant you that it is generally a younger crowd than what one would find at most medical meetings, but I see people of many ethnic backgrounds, and there are equal parts women and men.

What was striking to me, however, was when I walked into some of the smaller conference rooms where the SHM committee meetings were being held and where the leaders sat. That crowd didn’t seem nearly as diverse as the crowd in the bigger rooms. I remember asking one of my colleagues whether he had the same perception. He told me he didn’t see it that way. Then again, it dawned on me that he is white and works at an academic medical center. What if he walked into leadership committee meetings filled with women from under-represented minority groups who work in community hospitals? My guess is that he would notice right away.

But my perception is biased, so when I became SHM president last spring, I asked that we assemble some facts about our members. SHM pulled together a task force, which developed a survey and took a snapshot of SHM membership. Some of you may have received this survey; it was sent out to thousands of SHM members.

The survey results, which were shared recently with SHM’s board of directors, confirmed my suspicions: SHM membership is a reasonably diverse crowd when it comes to gender and race. When it came to the SHM committee membership, I was right and wrong. The percentage of women and under-represented minorities on SHM committees reflected overall SHM membership reasonably well, but it was clear that fewer women and under-represented minorities held senior leadership positions, such as committee chairs and positions on the board. I suspect this is no different at other professional medical societies and more of a commentary on medicine than on SHM.

The most striking difference, however, did not have to do with race or gender, but instead had to do with employment model. Hospitalists who work at places other than academic medical centers are clearly under-represented in SHM leadership positions.

Action Item: New Knowledge, Better Understanding

So what do we do with this information? Am I suggesting that we set aside special seats at the board table for specific types of people or special-interest groups, some seats just for women, and some just for hospitalists who work in community hospitals? I am not advocating any such action.

I did ask SHM leadership to initiate action to help us continually understand the makeup of SHM membership and compare it to representation at the leadership level. SHM leadership overwhelmingly agreed. This is the reason you are being asked to volunteer personal information when you renew your membership.

It is my hope and belief that SHM will use this information appropriately when they organize committees and build leadership teams. This information, if used appropriately, will help SHM leadership understand its potential bias and guard against unintended consequences of their actions.

I recognize that some people will argue that the questions being asked are not sufficiently comprehensive. We should also be asking about other individual characteristics. You may or may not be right, but at this time, I think we are taking a step in the right direction. Further steps may be forthcoming in the future, but let’s not let perfection be the enemy of good.

If you have any comments about this article, please contact me at JosephLi@HospitalMedicine.org. I’m also available on LinkedIn (JosephLi) and Twitter (@_JosephLi).

Dr. Li is president of SHM.

Who are you?

I am a 44-year-old Chinese-American male who works as a hospitalist at Beth Israel Deaconess Medical Center (BIDMC), an academic medical center in Boston. BIDMC is affiliated with Harvard Medical School, where I am an associate professor of medicine.

If you are about to join or renew your SHM membership, you can expect SHM to ask some questions it’s never asked before. What is your gender? What is your age? What is your ethnicity? I would not be surprised if you wondered why SHM is asking these questions. What does it have to do with my membership? Why are they asking now when they never asked before? I do not remember other professional medical societies asking these types of questions—should I be concerned? Is this an unnecessary invasion of privacy?

Call to Action

Nearly two years ago, when I had the good fortune of being elected SHM’s president-elect, I asked, What do we know about SHM members? As it turns out, it’s less than I thought we knew.

SHM has been in the survey business for years. The most visible survey is the annual productivity and compensation survey (see “Survey Insights,” p. TK). The data from this instrument have become very important, thanks to the many of you who have participated. In the early years of hospital medicine, everyone wanted to know how hard others were working and how much others were getting paid. If others had a better compensation package, it was the proof one needed to go marching into the C-suite asking for more support. If others were making less, it was the competitive advantage one needed to land the next hot-prospect hospitalist.

To be fair, I remember the surveys also asked about hospitalist age and employment model. But I don’t remember any questions about gender, race, or other personal information. The survey was the productivity and compensation survey, so maybe it had nothing to do with gender and race … but maybe it should.

Diverse, Yet Not So Much

Over the years, when I’ve walked the hallways at the SHM annual meeting, I got the sense that it was a reasonably diverse crowd. Take a look when you are at the San Diego Convention Center in April, and I expect you will agree. I grant you that it is generally a younger crowd than what one would find at most medical meetings, but I see people of many ethnic backgrounds, and there are equal parts women and men.

What was striking to me, however, was when I walked into some of the smaller conference rooms where the SHM committee meetings were being held and where the leaders sat. That crowd didn’t seem nearly as diverse as the crowd in the bigger rooms. I remember asking one of my colleagues whether he had the same perception. He told me he didn’t see it that way. Then again, it dawned on me that he is white and works at an academic medical center. What if he walked into leadership committee meetings filled with women from under-represented minority groups who work in community hospitals? My guess is that he would notice right away.

But my perception is biased, so when I became SHM president last spring, I asked that we assemble some facts about our members. SHM pulled together a task force, which developed a survey and took a snapshot of SHM membership. Some of you may have received this survey; it was sent out to thousands of SHM members.

The survey results, which were shared recently with SHM’s board of directors, confirmed my suspicions: SHM membership is a reasonably diverse crowd when it comes to gender and race. When it came to the SHM committee membership, I was right and wrong. The percentage of women and under-represented minorities on SHM committees reflected overall SHM membership reasonably well, but it was clear that fewer women and under-represented minorities held senior leadership positions, such as committee chairs and positions on the board. I suspect this is no different at other professional medical societies and more of a commentary on medicine than on SHM.

The most striking difference, however, did not have to do with race or gender, but instead had to do with employment model. Hospitalists who work at places other than academic medical centers are clearly under-represented in SHM leadership positions.

Action Item: New Knowledge, Better Understanding

So what do we do with this information? Am I suggesting that we set aside special seats at the board table for specific types of people or special-interest groups, some seats just for women, and some just for hospitalists who work in community hospitals? I am not advocating any such action.

I did ask SHM leadership to initiate action to help us continually understand the makeup of SHM membership and compare it to representation at the leadership level. SHM leadership overwhelmingly agreed. This is the reason you are being asked to volunteer personal information when you renew your membership.

It is my hope and belief that SHM will use this information appropriately when they organize committees and build leadership teams. This information, if used appropriately, will help SHM leadership understand its potential bias and guard against unintended consequences of their actions.

I recognize that some people will argue that the questions being asked are not sufficiently comprehensive. We should also be asking about other individual characteristics. You may or may not be right, but at this time, I think we are taking a step in the right direction. Further steps may be forthcoming in the future, but let’s not let perfection be the enemy of good.

If you have any comments about this article, please contact me at JosephLi@HospitalMedicine.org. I’m also available on LinkedIn (JosephLi) and Twitter (@_JosephLi).

Dr. Li is president of SHM.

In December, the U.S. Department of Health and Human Services (HHS) announced the selection of 32 organizations from 18 states as participants in the Pioneer Accountable Care Organization (ACO) initiative.

HHS developed this initiative with the hopes that they could save $1.1 billion over the next five years. Five of the 32 participating organizations are Massachusetts-based, including Beth Israel Deaconess Physician Organization (BIDPO) and Atrius Health. My hospitalist colleagues and I at Beth Israel Deaconess Medical Center (BIDMC) are BIDPO members; we also care for hospitalized patients for Atrius Health in Boston. So we will be caring for hospitalized patients involved in two of the 32 Pioneer ACOs.

Many of us are excited, but also understandably a bit anxious. Some of us are outright concerned. I suspect we are not alone. Many of you are in a similar position—being providers in a Pioneer ACO. My colleagues and are having conversations to increase our understanding of ACOs and the role of hospitalists in an ACO.

Nuts and Bolts

An ACO is a system to deliver and pay for healthcare by linking provider reimbursement to quality and cost of care for a defined population of patients. Think of it as a group of providers (primary-care physicians, ED doctors, hospitalists, medical and surgical specialists, etc.) who are bound by shared financial risks and rewards to work together to provide coordinated, high-quality, low-cost care for patients.

In the Pioneer ACO, groups of providers agree to manage the quality, costs, and overall care of the Medicare beneficiaries enrolled in the traditional fee-for-service program assigned to their ACO. The ACO model is designed to address some of the concerns of the traditional fee-for-service payment model, in which each provider offers services and submits their own bills separately. Under the fee-for-service model, the incentive is for each provider to provide as much care as possible, because payment is dependent on provision of more care rather than the provision of higher-quality care.

For example, there is little disincentive for PCPs to send patients to the ED if a patient needs evaluation, for any reason, when it is inconvenient for the PCP. Why keep outpatient clinic open during evenings and weekends when you could simply send the patient to the ED if they needed any sort of care? As an ED doctor, why not set a low threshold to admit patients to the hospital and mitigate any risk of a lawsuit by discharging the patient from the ED? As a hospitalist, why not discharge the patient to a skilled nursing care facility, where they will have more nursing supervision than at home, especially if the hospital, who is contributing to the hospitalist program bottom line, is monitoring your patients’ average length of stay?

Everyone is playing with everyone else’s money. Under the current system, there is little financial incentive for providers to work together in the provision of high-quality care. The ACO model is an attempt to create a model that will provide more integrated care by linking provider reimbursement to quality and cost of care.

Dr. Elliott Fisher at Dartmouth Medical School at Dartmouth College and others have identified several key principles for all ACOs:

• A strong primary-care base capable of being accountable for the quality and costs of care across the full continuum of care for a patient population;
• Provider reimbursement tied to quality improvements that also reduce overall costs; and
• Reliable performance measurement, to support quality improvement.

“ACO” may be a new term to many, but it is not new. Kaiser Permanente and HealthCare Partners Medical Group are examples of longstanding, successful ACOs.

You might be reading this and have arrived at the conclusion that Joe Li is convinced ACOs are the panacea for that ill known as the American healthcare system. That could not be further from the truth. I don’t think that the folks at Medicare are convinced, either. That is why there was a competitive process to select the 32 ACOs for this initiative. They chose provider groups that have experience working together. If ACOs are going to work, Medicare thinks these are the types of organizations that will be successful.

Interestingly, when one looks on the list of Pioneer participants, there are some notable absences. I don’t see Mayo Clinic or Cleveland Clinic. Hmmm. If these ACO “poster children” are not participating, should we? Perhaps they applied and HHS declined to accept their application, but I doubt it. These are the groups who already are ACOs. One can only assume that these organizations didn’t like the rules, or the financial rewards were not sufficiently attractive for them to participate.

Change Is Brewing

Regardless, the big question for hospitalists working in Pioneer groups is, How do we “succeed” in an ACO model? I believe that some of the same principles that allow hospitalists to succeed under the current model also apply under the ACO model. High-performing hospitalists and HM programs have:

Systems to monitor performance and provide feedback to providers with a plan for continuous quality improvement;

Established expectations for hospitalist communication with other providers, including PCPs, ED providers, subspecialists, nurses, and post-discharge care center facilities, among others; and

Multidisciplinary care teams providing evidence-based care with a focus on minimizing variations in care.

If ACOs are successful at providing high-quality care at lower costs, one could imagine changes to our healthcare system that will directly impact hospitalists. If ACOs are able to provide timely and comprehensive outpatient care, fewer patients will need care at acute-care hospitals. Efforts will be made to hospitalize patients at less-expensive community hospitals, instead of tertiary academic medical centers. The resultant smaller population of hospitalized patients will be sicker.

It’s not difficult to extrapolate on this new paradigm, as I can imagine hospitalists seeing fewer, sicker patients daily. These patients, as we all know, often require multiple visits per day. It is difficult to provide high-quality care to sick patients without doctors available in the hospital 24 hours a day, seven days a week. All hospitalists will need the skills to attend to critically ill, hospitalized patients. Hospitalists—and perhaps hospitals, if they are part of the ACO—will focus less on patient length of stay and more on keeping patients out of the hospitals. The cost of an entire readmission dwarfs the cost of one additional day in the hospital.

If you are a hospitalist providing care in a Pioneer ACO, I would love to hear how your practice is changing. Send me an email at JosephLi@hospitalmedicine.org, or message me via Twitter (@JosephLi) or LinkedIn: Joseph Li.

Dr. Li is president of SHM.

In December, the U.S. Department of Health and Human Services (HHS) announced the selection of 32 organizations from 18 states as participants in the Pioneer Accountable Care Organization (ACO) initiative.

HHS developed this initiative with the hopes that they could save $1.1 billion over the next five years. Five of the 32 participating organizations are Massachusetts-based, including Beth Israel Deaconess Physician Organization (BIDPO) and Atrius Health. My hospitalist colleagues and I at Beth Israel Deaconess Medical Center (BIDMC) are BIDPO members; we also care for hospitalized patients for Atrius Health in Boston. So we will be caring for hospitalized patients involved in two of the 32 Pioneer ACOs.

Many of us are excited, but also understandably a bit anxious. Some of us are outright concerned. I suspect we are not alone. Many of you are in a similar position—being providers in a Pioneer ACO. My colleagues and are having conversations to increase our understanding of ACOs and the role of hospitalists in an ACO.

Nuts and Bolts

An ACO is a system to deliver and pay for healthcare by linking provider reimbursement to quality and cost of care for a defined population of patients. Think of it as a group of providers (primary-care physicians, ED doctors, hospitalists, medical and surgical specialists, etc.) who are bound by shared financial risks and rewards to work together to provide coordinated, high-quality, low-cost care for patients.

In the Pioneer ACO, groups of providers agree to manage the quality, costs, and overall care of the Medicare beneficiaries enrolled in the traditional fee-for-service program assigned to their ACO. The ACO model is designed to address some of the concerns of the traditional fee-for-service payment model, in which each provider offers services and submits their own bills separately. Under the fee-for-service model, the incentive is for each provider to provide as much care as possible, because payment is dependent on provision of more care rather than the provision of higher-quality care.

For example, there is little disincentive for PCPs to send patients to the ED if a patient needs evaluation, for any reason, when it is inconvenient for the PCP. Why keep outpatient clinic open during evenings and weekends when you could simply send the patient to the ED if they needed any sort of care? As an ED doctor, why not set a low threshold to admit patients to the hospital and mitigate any risk of a lawsuit by discharging the patient from the ED? As a hospitalist, why not discharge the patient to a skilled nursing care facility, where they will have more nursing supervision than at home, especially if the hospital, who is contributing to the hospitalist program bottom line, is monitoring your patients’ average length of stay?

Everyone is playing with everyone else’s money. Under the current system, there is little financial incentive for providers to work together in the provision of high-quality care. The ACO model is an attempt to create a model that will provide more integrated care by linking provider reimbursement to quality and cost of care.

Dr. Elliott Fisher at Dartmouth Medical School at Dartmouth College and others have identified several key principles for all ACOs:

• A strong primary-care base capable of being accountable for the quality and costs of care across the full continuum of care for a patient population;
• Provider reimbursement tied to quality improvements that also reduce overall costs; and
• Reliable performance measurement, to support quality improvement.

“ACO” may be a new term to many, but it is not new. Kaiser Permanente and HealthCare Partners Medical Group are examples of longstanding, successful ACOs.

You might be reading this and have arrived at the conclusion that Joe Li is convinced ACOs are the panacea for that ill known as the American healthcare system. That could not be further from the truth. I don’t think that the folks at Medicare are convinced, either. That is why there was a competitive process to select the 32 ACOs for this initiative. They chose provider groups that have experience working together. If ACOs are going to work, Medicare thinks these are the types of organizations that will be successful.

Interestingly, when one looks on the list of Pioneer participants, there are some notable absences. I don’t see Mayo Clinic or Cleveland Clinic. Hmmm. If these ACO “poster children” are not participating, should we? Perhaps they applied and HHS declined to accept their application, but I doubt it. These are the groups who already are ACOs. One can only assume that these organizations didn’t like the rules, or the financial rewards were not sufficiently attractive for them to participate.

Change Is Brewing

Regardless, the big question for hospitalists working in Pioneer groups is, How do we “succeed” in an ACO model? I believe that some of the same principles that allow hospitalists to succeed under the current model also apply under the ACO model. High-performing hospitalists and HM programs have:

Systems to monitor performance and provide feedback to providers with a plan for continuous quality improvement;

Established expectations for hospitalist communication with other providers, including PCPs, ED providers, subspecialists, nurses, and post-discharge care center facilities, among others; and

Multidisciplinary care teams providing evidence-based care with a focus on minimizing variations in care.

If ACOs are successful at providing high-quality care at lower costs, one could imagine changes to our healthcare system that will directly impact hospitalists. If ACOs are able to provide timely and comprehensive outpatient care, fewer patients will need care at acute-care hospitals. Efforts will be made to hospitalize patients at less-expensive community hospitals, instead of tertiary academic medical centers. The resultant smaller population of hospitalized patients will be sicker.

It’s not difficult to extrapolate on this new paradigm, as I can imagine hospitalists seeing fewer, sicker patients daily. These patients, as we all know, often require multiple visits per day. It is difficult to provide high-quality care to sick patients without doctors available in the hospital 24 hours a day, seven days a week. All hospitalists will need the skills to attend to critically ill, hospitalized patients. Hospitalists—and perhaps hospitals, if they are part of the ACO—will focus less on patient length of stay and more on keeping patients out of the hospitals. The cost of an entire readmission dwarfs the cost of one additional day in the hospital.

If you are a hospitalist providing care in a Pioneer ACO, I would love to hear how your practice is changing. Send me an email at JosephLi@hospitalmedicine.org, or message me via Twitter (@JosephLi) or LinkedIn: Joseph Li.

Dr. Li is president of SHM.

In December, the U.S. Department of Health and Human Services (HHS) announced the selection of 32 organizations from 18 states as participants in the Pioneer Accountable Care Organization (ACO) initiative.

HHS developed this initiative with the hopes that they could save $1.1 billion over the next five years. Five of the 32 participating organizations are Massachusetts-based, including Beth Israel Deaconess Physician Organization (BIDPO) and Atrius Health. My hospitalist colleagues and I at Beth Israel Deaconess Medical Center (BIDMC) are BIDPO members; we also care for hospitalized patients for Atrius Health in Boston. So we will be caring for hospitalized patients involved in two of the 32 Pioneer ACOs.

Many of us are excited, but also understandably a bit anxious. Some of us are outright concerned. I suspect we are not alone. Many of you are in a similar position—being providers in a Pioneer ACO. My colleagues and are having conversations to increase our understanding of ACOs and the role of hospitalists in an ACO.

Nuts and Bolts

An ACO is a system to deliver and pay for healthcare by linking provider reimbursement to quality and cost of care for a defined population of patients. Think of it as a group of providers (primary-care physicians, ED doctors, hospitalists, medical and surgical specialists, etc.) who are bound by shared financial risks and rewards to work together to provide coordinated, high-quality, low-cost care for patients.

In the Pioneer ACO, groups of providers agree to manage the quality, costs, and overall care of the Medicare beneficiaries enrolled in the traditional fee-for-service program assigned to their ACO. The ACO model is designed to address some of the concerns of the traditional fee-for-service payment model, in which each provider offers services and submits their own bills separately. Under the fee-for-service model, the incentive is for each provider to provide as much care as possible, because payment is dependent on provision of more care rather than the provision of higher-quality care.

For example, there is little disincentive for PCPs to send patients to the ED if a patient needs evaluation, for any reason, when it is inconvenient for the PCP. Why keep outpatient clinic open during evenings and weekends when you could simply send the patient to the ED if they needed any sort of care? As an ED doctor, why not set a low threshold to admit patients to the hospital and mitigate any risk of a lawsuit by discharging the patient from the ED? As a hospitalist, why not discharge the patient to a skilled nursing care facility, where they will have more nursing supervision than at home, especially if the hospital, who is contributing to the hospitalist program bottom line, is monitoring your patients’ average length of stay?

Everyone is playing with everyone else’s money. Under the current system, there is little financial incentive for providers to work together in the provision of high-quality care. The ACO model is an attempt to create a model that will provide more integrated care by linking provider reimbursement to quality and cost of care.

Dr. Elliott Fisher at Dartmouth Medical School at Dartmouth College and others have identified several key principles for all ACOs:

• A strong primary-care base capable of being accountable for the quality and costs of care across the full continuum of care for a patient population;
• Provider reimbursement tied to quality improvements that also reduce overall costs; and
• Reliable performance measurement, to support quality improvement.

“ACO” may be a new term to many, but it is not new. Kaiser Permanente and HealthCare Partners Medical Group are examples of longstanding, successful ACOs.

You might be reading this and have arrived at the conclusion that Joe Li is convinced ACOs are the panacea for that ill known as the American healthcare system. That could not be further from the truth. I don’t think that the folks at Medicare are convinced, either. That is why there was a competitive process to select the 32 ACOs for this initiative. They chose provider groups that have experience working together. If ACOs are going to work, Medicare thinks these are the types of organizations that will be successful.

Interestingly, when one looks on the list of Pioneer participants, there are some notable absences. I don’t see Mayo Clinic or Cleveland Clinic. Hmmm. If these ACO “poster children” are not participating, should we? Perhaps they applied and HHS declined to accept their application, but I doubt it. These are the groups who already are ACOs. One can only assume that these organizations didn’t like the rules, or the financial rewards were not sufficiently attractive for them to participate.

Change Is Brewing

Regardless, the big question for hospitalists working in Pioneer groups is, How do we “succeed” in an ACO model? I believe that some of the same principles that allow hospitalists to succeed under the current model also apply under the ACO model. High-performing hospitalists and HM programs have:

Systems to monitor performance and provide feedback to providers with a plan for continuous quality improvement;

Established expectations for hospitalist communication with other providers, including PCPs, ED providers, subspecialists, nurses, and post-discharge care center facilities, among others; and

Multidisciplinary care teams providing evidence-based care with a focus on minimizing variations in care.

If ACOs are successful at providing high-quality care at lower costs, one could imagine changes to our healthcare system that will directly impact hospitalists. If ACOs are able to provide timely and comprehensive outpatient care, fewer patients will need care at acute-care hospitals. Efforts will be made to hospitalize patients at less-expensive community hospitals, instead of tertiary academic medical centers. The resultant smaller population of hospitalized patients will be sicker.

It’s not difficult to extrapolate on this new paradigm, as I can imagine hospitalists seeing fewer, sicker patients daily. These patients, as we all know, often require multiple visits per day. It is difficult to provide high-quality care to sick patients without doctors available in the hospital 24 hours a day, seven days a week. All hospitalists will need the skills to attend to critically ill, hospitalized patients. Hospitalists—and perhaps hospitals, if they are part of the ACO—will focus less on patient length of stay and more on keeping patients out of the hospitals. The cost of an entire readmission dwarfs the cost of one additional day in the hospital.

If you are a hospitalist providing care in a Pioneer ACO, I would love to hear how your practice is changing. Send me an email at JosephLi@hospitalmedicine.org, or message me via Twitter (@JosephLi) or LinkedIn: Joseph Li.

Dr. Li is president of SHM.

As a charter member of SHM, I have been paying my annual membership dues since the late 1990s. For those of you who are SHM members, I thank you. Our small group, which organized in the late 1990s, has grown to thousands. In addition to improving patient care, your SHM membership dues help hospitalists advocate for hospitalists and support the profession we call hospital medicine.

In addition to joining SHM, there are many other ways to support SHM and do your part to support the profession. As a longtime leader of the Boston SHM chapter, I encourage you to not only attend your local SHM chapter meetings, but also become involved in its operation. You might be surprised where your attendance and participation at local SHM chapter meetings lead you.

My friend Kathleen Finn, MD, and I first organized our “Boston Hospitalist Meetings” in the late 1990s, when we signed up as members of NAIP (National Association of Inpatient Physicians), which later became SHM. Our goal for meetings was pretty simple: We wanted a venue for Boston area hospitalists to share ideas and figure out what we were supposed to do as “hospitalists.” Our first meeting was held at Beth Israel Deaconess Medical Center, and we invited Win Whitcomb, MD, MHM, to speak. Win is a cofounder of NAIP and resided in central Massachusetts. Never could I have imagined back in the late 1990s that, in 2011, Kathleen and I would still be holding our quarterly meetings, nor could I imagine that I would become SHM’s president. I am proud of the part we played in shaping HM locally, regionally, and nationally.

Something else I am proud of is the fact that SHM members have a voice when it comes to electing its leaders. Today I received an email asking me to cast my vote for the SHM board of directors. Like me, some of you are members of other professional medical societies. Think about this: How many other organizations ask you for your vote when it comes to selecting its leaders? The board of directors set the direction for SHM and our profession. They not only choose the editors for our publications (The Hospitalist and Journal of Hospital Medicine) and the director of our annual meeting, but they also hire our CEO and elect our president. They make some decisions that seem pretty important to our organization and to our profession, don’t you think?

Here is where it gets a bit puzzling to me. Despite the size of our society (around 10,000 members), relatively few SHM members choose to exercise their right to vote.

I liken the right to vote to getting the flu shot: Nobody seems to miss the flu shot until we hear there is a vaccine shortage. Then we are outraged there aren’t enough vaccines for everyone. Let’s think about the alternative. What if SHM were to change the way it picks its leaders? Why not act like most other professional medical societies and do away with membership elections and ask existing leadership to hand-select the organization’s future leaders? “We know better who should be leading our organization!” Would we be surprised when people pick their own friends and colleagues to replace them on the board? That doesn’t sound “American,” does it? What if we were to ask congressmen to select their own members? As costly and cumbersome as our election process might be (think “hanging chads” in Florida), there is something comforting in knowing that I have a voice in electing my leaders.

The right to vote is a founding principle of our great nation, right? It is the reason why many of us and/or our ancestors came to the U.S. My maternal grandparents left China in the 1950s so they could live “free” in Hong Kong. My parents moved our family to the U.S. in the mid-1970s because of the anticipated “handover” of Hong Kong from Great Britain to China in 1997. Look back far enough in your family tree, and you likely will find similar stories.

Should we be concerned with the “as is” process and plod along with our annual SHM elections, even if voter turnout is low? Is there a problem with the status quo? Voter apathy is a bigger problem than we may realize. Low voter turnout creates the potential for any one group to insidiously wrest over the control of any organization’s agenda.

There are typically three or four board seats up for election annually. This means half the 12-person board could change every two years. One could easily imagine a scenario in which a special-interest group could elect directors with a like-minded agenda simply by generating increased voter turnout over two election cycles.

Sound crazy? Is this is Joe’s “Occupy SHM” conspiracy theory? I don’t think so. Take a look around and ask yourself why there are multiple professional societies that represent ED physicians or pulmonary/critical-care physicians. The list goes on and on when it comes to medical societies. With enough numbers, groups with their own interests can take over an organization and advance their own agenda. Overnight, we could see the hospitalist community splinter into multiple professional societies, each with its own agenda. This could happen to us. For example, we could have a society for academic hospitalists, another for community hospitalists, etc.

I think our patients and profession are better served long-term if there is one professional organization representing all hospitalists, whether you are a pediatrician, family physician, nurse practitioner, internist, etc., and whether you are self-employed, work for a management company, work for a hospital, etc.

The list of special-interest groups could go on and on. But it should be viewed as a strength, not a weakness, to preserve one professional society that represents all of hospital medicine’s interests. I am interested in your thoughts on how we can increase voter turnout for SHM’s board of director elections. Please email me at JosephLi@HospitalMedicine.org.

Dr. Li is president of SHM.

As a charter member of SHM, I have been paying my annual membership dues since the late 1990s. For those of you who are SHM members, I thank you. Our small group, which organized in the late 1990s, has grown to thousands. In addition to improving patient care, your SHM membership dues help hospitalists advocate for hospitalists and support the profession we call hospital medicine.

In addition to joining SHM, there are many other ways to support SHM and do your part to support the profession. As a longtime leader of the Boston SHM chapter, I encourage you to not only attend your local SHM chapter meetings, but also become involved in its operation. You might be surprised where your attendance and participation at local SHM chapter meetings lead you.

My friend Kathleen Finn, MD, and I first organized our “Boston Hospitalist Meetings” in the late 1990s, when we signed up as members of NAIP (National Association of Inpatient Physicians), which later became SHM. Our goal for meetings was pretty simple: We wanted a venue for Boston area hospitalists to share ideas and figure out what we were supposed to do as “hospitalists.” Our first meeting was held at Beth Israel Deaconess Medical Center, and we invited Win Whitcomb, MD, MHM, to speak. Win is a cofounder of NAIP and resided in central Massachusetts. Never could I have imagined back in the late 1990s that, in 2011, Kathleen and I would still be holding our quarterly meetings, nor could I imagine that I would become SHM’s president. I am proud of the part we played in shaping HM locally, regionally, and nationally.

Something else I am proud of is the fact that SHM members have a voice when it comes to electing its leaders. Today I received an email asking me to cast my vote for the SHM board of directors. Like me, some of you are members of other professional medical societies. Think about this: How many other organizations ask you for your vote when it comes to selecting its leaders? The board of directors set the direction for SHM and our profession. They not only choose the editors for our publications (The Hospitalist and Journal of Hospital Medicine) and the director of our annual meeting, but they also hire our CEO and elect our president. They make some decisions that seem pretty important to our organization and to our profession, don’t you think?

Here is where it gets a bit puzzling to me. Despite the size of our society (around 10,000 members), relatively few SHM members choose to exercise their right to vote.

I liken the right to vote to getting the flu shot: Nobody seems to miss the flu shot until we hear there is a vaccine shortage. Then we are outraged there aren’t enough vaccines for everyone. Let’s think about the alternative. What if SHM were to change the way it picks its leaders? Why not act like most other professional medical societies and do away with membership elections and ask existing leadership to hand-select the organization’s future leaders? “We know better who should be leading our organization!” Would we be surprised when people pick their own friends and colleagues to replace them on the board? That doesn’t sound “American,” does it? What if we were to ask congressmen to select their own members? As costly and cumbersome as our election process might be (think “hanging chads” in Florida), there is something comforting in knowing that I have a voice in electing my leaders.

The right to vote is a founding principle of our great nation, right? It is the reason why many of us and/or our ancestors came to the U.S. My maternal grandparents left China in the 1950s so they could live “free” in Hong Kong. My parents moved our family to the U.S. in the mid-1970s because of the anticipated “handover” of Hong Kong from Great Britain to China in 1997. Look back far enough in your family tree, and you likely will find similar stories.

Should we be concerned with the “as is” process and plod along with our annual SHM elections, even if voter turnout is low? Is there a problem with the status quo? Voter apathy is a bigger problem than we may realize. Low voter turnout creates the potential for any one group to insidiously wrest over the control of any organization’s agenda.

There are typically three or four board seats up for election annually. This means half the 12-person board could change every two years. One could easily imagine a scenario in which a special-interest group could elect directors with a like-minded agenda simply by generating increased voter turnout over two election cycles.

Sound crazy? Is this is Joe’s “Occupy SHM” conspiracy theory? I don’t think so. Take a look around and ask yourself why there are multiple professional societies that represent ED physicians or pulmonary/critical-care physicians. The list goes on and on when it comes to medical societies. With enough numbers, groups with their own interests can take over an organization and advance their own agenda. Overnight, we could see the hospitalist community splinter into multiple professional societies, each with its own agenda. This could happen to us. For example, we could have a society for academic hospitalists, another for community hospitalists, etc.

I think our patients and profession are better served long-term if there is one professional organization representing all hospitalists, whether you are a pediatrician, family physician, nurse practitioner, internist, etc., and whether you are self-employed, work for a management company, work for a hospital, etc.

The list of special-interest groups could go on and on. But it should be viewed as a strength, not a weakness, to preserve one professional society that represents all of hospital medicine’s interests. I am interested in your thoughts on how we can increase voter turnout for SHM’s board of director elections. Please email me at JosephLi@HospitalMedicine.org.

Dr. Li is president of SHM.

As a charter member of SHM, I have been paying my annual membership dues since the late 1990s. For those of you who are SHM members, I thank you. Our small group, which organized in the late 1990s, has grown to thousands. In addition to improving patient care, your SHM membership dues help hospitalists advocate for hospitalists and support the profession we call hospital medicine.

In addition to joining SHM, there are many other ways to support SHM and do your part to support the profession. As a longtime leader of the Boston SHM chapter, I encourage you to not only attend your local SHM chapter meetings, but also become involved in its operation. You might be surprised where your attendance and participation at local SHM chapter meetings lead you.

My friend Kathleen Finn, MD, and I first organized our “Boston Hospitalist Meetings” in the late 1990s, when we signed up as members of NAIP (National Association of Inpatient Physicians), which later became SHM. Our goal for meetings was pretty simple: We wanted a venue for Boston area hospitalists to share ideas and figure out what we were supposed to do as “hospitalists.” Our first meeting was held at Beth Israel Deaconess Medical Center, and we invited Win Whitcomb, MD, MHM, to speak. Win is a cofounder of NAIP and resided in central Massachusetts. Never could I have imagined back in the late 1990s that, in 2011, Kathleen and I would still be holding our quarterly meetings, nor could I imagine that I would become SHM’s president. I am proud of the part we played in shaping HM locally, regionally, and nationally.

Something else I am proud of is the fact that SHM members have a voice when it comes to electing its leaders. Today I received an email asking me to cast my vote for the SHM board of directors. Like me, some of you are members of other professional medical societies. Think about this: How many other organizations ask you for your vote when it comes to selecting its leaders? The board of directors set the direction for SHM and our profession. They not only choose the editors for our publications (The Hospitalist and Journal of Hospital Medicine) and the director of our annual meeting, but they also hire our CEO and elect our president. They make some decisions that seem pretty important to our organization and to our profession, don’t you think?

Here is where it gets a bit puzzling to me. Despite the size of our society (around 10,000 members), relatively few SHM members choose to exercise their right to vote.

I liken the right to vote to getting the flu shot: Nobody seems to miss the flu shot until we hear there is a vaccine shortage. Then we are outraged there aren’t enough vaccines for everyone. Let’s think about the alternative. What if SHM were to change the way it picks its leaders? Why not act like most other professional medical societies and do away with membership elections and ask existing leadership to hand-select the organization’s future leaders? “We know better who should be leading our organization!” Would we be surprised when people pick their own friends and colleagues to replace them on the board? That doesn’t sound “American,” does it? What if we were to ask congressmen to select their own members? As costly and cumbersome as our election process might be (think “hanging chads” in Florida), there is something comforting in knowing that I have a voice in electing my leaders.

The right to vote is a founding principle of our great nation, right? It is the reason why many of us and/or our ancestors came to the U.S. My maternal grandparents left China in the 1950s so they could live “free” in Hong Kong. My parents moved our family to the U.S. in the mid-1970s because of the anticipated “handover” of Hong Kong from Great Britain to China in 1997. Look back far enough in your family tree, and you likely will find similar stories.

Should we be concerned with the “as is” process and plod along with our annual SHM elections, even if voter turnout is low? Is there a problem with the status quo? Voter apathy is a bigger problem than we may realize. Low voter turnout creates the potential for any one group to insidiously wrest over the control of any organization’s agenda.

There are typically three or four board seats up for election annually. This means half the 12-person board could change every two years. One could easily imagine a scenario in which a special-interest group could elect directors with a like-minded agenda simply by generating increased voter turnout over two election cycles.

Sound crazy? Is this is Joe’s “Occupy SHM” conspiracy theory? I don’t think so. Take a look around and ask yourself why there are multiple professional societies that represent ED physicians or pulmonary/critical-care physicians. The list goes on and on when it comes to medical societies. With enough numbers, groups with their own interests can take over an organization and advance their own agenda. Overnight, we could see the hospitalist community splinter into multiple professional societies, each with its own agenda. This could happen to us. For example, we could have a society for academic hospitalists, another for community hospitalists, etc.

I think our patients and profession are better served long-term if there is one professional organization representing all hospitalists, whether you are a pediatrician, family physician, nurse practitioner, internist, etc., and whether you are self-employed, work for a management company, work for a hospital, etc.

The list of special-interest groups could go on and on. But it should be viewed as a strength, not a weakness, to preserve one professional society that represents all of hospital medicine’s interests. I am interested in your thoughts on how we can increase voter turnout for SHM’s board of director elections. Please email me at JosephLi@HospitalMedicine.org.

Dr. Li is president of SHM.

Steve Jobs was right. Challenges create opportunity. What are the opportunities in hospital medicine today? Take a lesson from the iPhone: Give them what they need when they need it.

I was in a restaurant in Denver the night I saw the news on the TV. “Steve Jobs dead at the age of 56.” Was I surprised? Yes…and no. Everyone knew he was seriously ill; he acknowledged as much when he stepped down as Apple CEO. While not unexpected, his death was still surprising and an emotional jolt.

I quickly finished my meal and went back to my hotel room, where I turned on CNN. I sat back and watched Anderson Cooper talk about Jobs’ life and legacy. Apple co-founder Steve Wozniak was on the telephone with Cooper. Wozniak said when he heard the news, he felt numb, much like he did when he heard about the deaths of John Lennon or President Kennedy.

I felt the same way. I never knew Steve Jobs, but Steve Jobs knew me. He influenced my life in ways unimaginable.

A Revolutionary Persona

On the flight to Denver, I passed time watching a movie produced by Pixar, the movie studio he founded. When I landed, I used an app on my iPhone to find this restaurant, which was close to my hotel and had great reviews. I am typing this month’s column on my Macintosh laptop. How did I let someone I never knew get so close to me and have so much influence on my life?

This is Steve Jobs’ legacy. He did what others couldn’t do. He didn’t invent the personal computer, but he made one that was easy to use. He didn’t create animation, but he showed Hollywood how to create more intriguing movies faster and cheaper. (The smartest thing Disney did was to buy out Pixar before Pixar grew big enough to buy them.)

He revolutionized the music industry. Remember when Napster had the music industry on its heels? Recording labels were suing people and college kids were going to jail for downloading pirated songs. Seemed crazy to send kids off to jail for lifting a few songs, but it was happening. Then came the iPod and iTunes. Not only could I pay 99 cents for a song, I could carry my entire music library in my pocket. Duh … why didn’t I think of that? And he did it all while living with pancreatic neuroendocrine cancer!

One of the things I watched on CNN that evening was a segment from the commencement speech Jobs gave to Stanford University’s graduating class several years ago. He had just recovered from his surgery (visit http://news.stanford.edu/news/2005/june15/jobs-061505.html for the complete transcript). He described how his firing from Apple spurred creativity and resulted in innovation.

“Getting fired from Apple was the best thing that could have ever happened to me,” he said. “The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.”

This made me think back to 1994, the year I graduated from medical school and about two years before Drs. Wachter and Goldman coined the term “hospitalist” in that fateful New England Journal of Medicine article.¹ In 1994, I could not have imagined the iPhone; I could not have predicted the field of hospital medicine. Don't worry if you couldn’t, either. I really think that if this is how we define innovation, we have set the bar too high. Innovation does not have to be complicated. In fact, the greatest innovations are simple. Hand your iPhone to a five-year-old and they can figure it out. Can you do that with a PC?

Challenges Ahead, Ongoing

How does this apply to hospital medicine? These are challenging times for hospitalists. American healthcare costs too much, and some people are saying hospitalists are part of the problem. Hospitalists are discharging more patients than ever from our nation’s hospitals, and more patients than ever are finding themselves readmitted within 30 days. Quality and process improvement is the mantra in healthcare today, and too many hospitalists have little understanding of what is necessary to participate in quality and process improvement.

Steve Jobs got fired from the company he created. Could hospitalists be removed from the program they started? Jobs was right. Challenges create opportunity. What are the opportunities in HM today? Take a lesson from the iPhone: Give them what they need when they need it.

For example, why do so many hospitalist programs staff in-house only during daytime hours? Patients don’t become acutely ill only during the day. Most of us will be hospitalized at some point in our lives. Will there be a hospitalist to see you when you are short of breath or having chest pain? Hospitalists need to be in house 24 hours a day, seven days a week, providing care when patients need it. I know that we don’t have enough money to pay for this and we don’t have enough hospitalists to staff 24/7, but that is the innovation part. I can assure you that while the iPhone is easy for the end-user, an incredible amount of infrastructure had to be created in order to support that easy-to-use experience for the consumer. Jobs and Apple overcame hurdles to create the iPhone. It’s our job to overcome the hurdles to provide safe, timely, and high-value care for our patients.

Steve Jobs’ legacy is Apple.

What is your legacy?

A Call for Research

Most of you are aware that Jobs died from pancreatic neuroendocrine cancer. This is a relatively rare disease, which is in dire need of additional research. Patients with rare diseases find themselves in the difficult position of trying to understand why little is being done to help them.

I, unfortunately, know something about this, as someone very close to me has this disease. Research requires funding. One way to honor Jobs’ legacy is to support pancreatic neuroendocrine cancer research. One organization I have personally supported is the Caring for Carcinoid Foundation. This foundation has contributed millions of dollars toward carcinoid and neuroendocrine tumor research.

If you want to learn more about the Caring for Carcinoid Foundation, visit www.caringforcarcinoid.org.

Dr. Li is president of SHM.

Reference

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American healthcare system. N Engl J Med. 1996;335:514-517.

Steve Jobs was right. Challenges create opportunity. What are the opportunities in hospital medicine today? Take a lesson from the iPhone: Give them what they need when they need it.

I was in a restaurant in Denver the night I saw the news on the TV. “Steve Jobs dead at the age of 56.” Was I surprised? Yes…and no. Everyone knew he was seriously ill; he acknowledged as much when he stepped down as Apple CEO. While not unexpected, his death was still surprising and an emotional jolt.

I quickly finished my meal and went back to my hotel room, where I turned on CNN. I sat back and watched Anderson Cooper talk about Jobs’ life and legacy. Apple co-founder Steve Wozniak was on the telephone with Cooper. Wozniak said when he heard the news, he felt numb, much like he did when he heard about the deaths of John Lennon or President Kennedy.

I felt the same way. I never knew Steve Jobs, but Steve Jobs knew me. He influenced my life in ways unimaginable.

A Revolutionary Persona

On the flight to Denver, I passed time watching a movie produced by Pixar, the movie studio he founded. When I landed, I used an app on my iPhone to find this restaurant, which was close to my hotel and had great reviews. I am typing this month’s column on my Macintosh laptop. How did I let someone I never knew get so close to me and have so much influence on my life?

This is Steve Jobs’ legacy. He did what others couldn’t do. He didn’t invent the personal computer, but he made one that was easy to use. He didn’t create animation, but he showed Hollywood how to create more intriguing movies faster and cheaper. (The smartest thing Disney did was to buy out Pixar before Pixar grew big enough to buy them.)

He revolutionized the music industry. Remember when Napster had the music industry on its heels? Recording labels were suing people and college kids were going to jail for downloading pirated songs. Seemed crazy to send kids off to jail for lifting a few songs, but it was happening. Then came the iPod and iTunes. Not only could I pay 99 cents for a song, I could carry my entire music library in my pocket. Duh … why didn’t I think of that? And he did it all while living with pancreatic neuroendocrine cancer!

One of the things I watched on CNN that evening was a segment from the commencement speech Jobs gave to Stanford University’s graduating class several years ago. He had just recovered from his surgery (visit http://news.stanford.edu/news/2005/june15/jobs-061505.html for the complete transcript). He described how his firing from Apple spurred creativity and resulted in innovation.

“Getting fired from Apple was the best thing that could have ever happened to me,” he said. “The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.”

This made me think back to 1994, the year I graduated from medical school and about two years before Drs. Wachter and Goldman coined the term “hospitalist” in that fateful New England Journal of Medicine article.¹ In 1994, I could not have imagined the iPhone; I could not have predicted the field of hospital medicine. Don't worry if you couldn’t, either. I really think that if this is how we define innovation, we have set the bar too high. Innovation does not have to be complicated. In fact, the greatest innovations are simple. Hand your iPhone to a five-year-old and they can figure it out. Can you do that with a PC?

Challenges Ahead, Ongoing

How does this apply to hospital medicine? These are challenging times for hospitalists. American healthcare costs too much, and some people are saying hospitalists are part of the problem. Hospitalists are discharging more patients than ever from our nation’s hospitals, and more patients than ever are finding themselves readmitted within 30 days. Quality and process improvement is the mantra in healthcare today, and too many hospitalists have little understanding of what is necessary to participate in quality and process improvement.

Steve Jobs got fired from the company he created. Could hospitalists be removed from the program they started? Jobs was right. Challenges create opportunity. What are the opportunities in HM today? Take a lesson from the iPhone: Give them what they need when they need it.

For example, why do so many hospitalist programs staff in-house only during daytime hours? Patients don’t become acutely ill only during the day. Most of us will be hospitalized at some point in our lives. Will there be a hospitalist to see you when you are short of breath or having chest pain? Hospitalists need to be in house 24 hours a day, seven days a week, providing care when patients need it. I know that we don’t have enough money to pay for this and we don’t have enough hospitalists to staff 24/7, but that is the innovation part. I can assure you that while the iPhone is easy for the end-user, an incredible amount of infrastructure had to be created in order to support that easy-to-use experience for the consumer. Jobs and Apple overcame hurdles to create the iPhone. It’s our job to overcome the hurdles to provide safe, timely, and high-value care for our patients.

Steve Jobs’ legacy is Apple.

What is your legacy?

A Call for Research

Most of you are aware that Jobs died from pancreatic neuroendocrine cancer. This is a relatively rare disease, which is in dire need of additional research. Patients with rare diseases find themselves in the difficult position of trying to understand why little is being done to help them.

I, unfortunately, know something about this, as someone very close to me has this disease. Research requires funding. One way to honor Jobs’ legacy is to support pancreatic neuroendocrine cancer research. One organization I have personally supported is the Caring for Carcinoid Foundation. This foundation has contributed millions of dollars toward carcinoid and neuroendocrine tumor research.

If you want to learn more about the Caring for Carcinoid Foundation, visit www.caringforcarcinoid.org.

Dr. Li is president of SHM.

Reference

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American healthcare system. N Engl J Med. 1996;335:514-517.

Steve Jobs was right. Challenges create opportunity. What are the opportunities in hospital medicine today? Take a lesson from the iPhone: Give them what they need when they need it.

I was in a restaurant in Denver the night I saw the news on the TV. “Steve Jobs dead at the age of 56.” Was I surprised? Yes…and no. Everyone knew he was seriously ill; he acknowledged as much when he stepped down as Apple CEO. While not unexpected, his death was still surprising and an emotional jolt.

I quickly finished my meal and went back to my hotel room, where I turned on CNN. I sat back and watched Anderson Cooper talk about Jobs’ life and legacy. Apple co-founder Steve Wozniak was on the telephone with Cooper. Wozniak said when he heard the news, he felt numb, much like he did when he heard about the deaths of John Lennon or President Kennedy.

I felt the same way. I never knew Steve Jobs, but Steve Jobs knew me. He influenced my life in ways unimaginable.

A Revolutionary Persona

On the flight to Denver, I passed time watching a movie produced by Pixar, the movie studio he founded. When I landed, I used an app on my iPhone to find this restaurant, which was close to my hotel and had great reviews. I am typing this month’s column on my Macintosh laptop. How did I let someone I never knew get so close to me and have so much influence on my life?

This is Steve Jobs’ legacy. He did what others couldn’t do. He didn’t invent the personal computer, but he made one that was easy to use. He didn’t create animation, but he showed Hollywood how to create more intriguing movies faster and cheaper. (The smartest thing Disney did was to buy out Pixar before Pixar grew big enough to buy them.)

He revolutionized the music industry. Remember when Napster had the music industry on its heels? Recording labels were suing people and college kids were going to jail for downloading pirated songs. Seemed crazy to send kids off to jail for lifting a few songs, but it was happening. Then came the iPod and iTunes. Not only could I pay 99 cents for a song, I could carry my entire music library in my pocket. Duh … why didn’t I think of that? And he did it all while living with pancreatic neuroendocrine cancer!

One of the things I watched on CNN that evening was a segment from the commencement speech Jobs gave to Stanford University’s graduating class several years ago. He had just recovered from his surgery (visit http://news.stanford.edu/news/2005/june15/jobs-061505.html for the complete transcript). He described how his firing from Apple spurred creativity and resulted in innovation.

“Getting fired from Apple was the best thing that could have ever happened to me,” he said. “The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.”

This made me think back to 1994, the year I graduated from medical school and about two years before Drs. Wachter and Goldman coined the term “hospitalist” in that fateful New England Journal of Medicine article.¹ In 1994, I could not have imagined the iPhone; I could not have predicted the field of hospital medicine. Don't worry if you couldn’t, either. I really think that if this is how we define innovation, we have set the bar too high. Innovation does not have to be complicated. In fact, the greatest innovations are simple. Hand your iPhone to a five-year-old and they can figure it out. Can you do that with a PC?

Challenges Ahead, Ongoing

How does this apply to hospital medicine? These are challenging times for hospitalists. American healthcare costs too much, and some people are saying hospitalists are part of the problem. Hospitalists are discharging more patients than ever from our nation’s hospitals, and more patients than ever are finding themselves readmitted within 30 days. Quality and process improvement is the mantra in healthcare today, and too many hospitalists have little understanding of what is necessary to participate in quality and process improvement.

Steve Jobs got fired from the company he created. Could hospitalists be removed from the program they started? Jobs was right. Challenges create opportunity. What are the opportunities in HM today? Take a lesson from the iPhone: Give them what they need when they need it.

For example, why do so many hospitalist programs staff in-house only during daytime hours? Patients don’t become acutely ill only during the day. Most of us will be hospitalized at some point in our lives. Will there be a hospitalist to see you when you are short of breath or having chest pain? Hospitalists need to be in house 24 hours a day, seven days a week, providing care when patients need it. I know that we don’t have enough money to pay for this and we don’t have enough hospitalists to staff 24/7, but that is the innovation part. I can assure you that while the iPhone is easy for the end-user, an incredible amount of infrastructure had to be created in order to support that easy-to-use experience for the consumer. Jobs and Apple overcame hurdles to create the iPhone. It’s our job to overcome the hurdles to provide safe, timely, and high-value care for our patients.

Steve Jobs’ legacy is Apple.

What is your legacy?

A Call for Research

Most of you are aware that Jobs died from pancreatic neuroendocrine cancer. This is a relatively rare disease, which is in dire need of additional research. Patients with rare diseases find themselves in the difficult position of trying to understand why little is being done to help them.

I, unfortunately, know something about this, as someone very close to me has this disease. Research requires funding. One way to honor Jobs’ legacy is to support pancreatic neuroendocrine cancer research. One organization I have personally supported is the Caring for Carcinoid Foundation. This foundation has contributed millions of dollars toward carcinoid and neuroendocrine tumor research.

If you want to learn more about the Caring for Carcinoid Foundation, visit www.caringforcarcinoid.org.

Dr. Li is president of SHM.

Reference

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American healthcare system. N Engl J Med. 1996;335:514-517.

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

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

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

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

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

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

For those of you who were kind enough to pick up my column in The Hospitalist last month (see “A Critical First Step,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system to purchase healthcare and that all healthcare providers, including hospitalists, will be increasingly judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality÷cost.)

I believe that the hospitalist programs that are going to be the most successful are those that are able to continually measure their quality and costs, allowing them to make improvements. These are the groups that will understand their own performance well before others make their “value” judgments.

History Lesson

In his famous book “The Wealth of Nations,” 18th-century economist Adam Smith used the example of a pin factory to show how specialization improved human productivity. The process of producing a pin was broken down into many small tasks, each done by a different “specialist.” This resulted not only in increased efficiency, but also increased productivity. The factory was then able to reinvest the profits in even more efficient machinery, which was able to reduce labor costs. The lower cost for pins was a benefit, and it was spread across the entire population.

We have seen similar examples in American healthcare. In many American hospitals, the images of CT scans performed during nighttime hours are transmitted to India and other Asian countries where highly trained radiologists interpret the scans and transmit their interpretations back to the physicians caring for the patients. Like the pin factory workers, these radiologists are specialists with unique skills; they operate specialized machinery to make the system more efficient with resultant lower costs. At the level of the individual patient, this system means getting test results back in a more timely fashion. Increased quality and lower costs: These are high-value providers.

It should be obvious to us that hospitalists are “specialists.” While most hospitalists are trained as general internists, pediatricians, and family physicians, you and I are “specialists” who focus our efforts on the care of hospitalized patients. In the late 1990s, much was made of the fact that hospitalists were able to reduce hospital costs because of decreased length of stay (LOS) for patients, without any adverse effects on clinical outcomes. Today, hospitalists number more than 30,000 nationwide, and virtually all American hospitals with more than 200 beds have hospitalists.

Hospitals hired hospitalists in droves because they were perceived as “inpatient specialists” who were able to reduce the cost of healthcare delivery. Like lower pin costs, this economic benefit was spread across the entire population. Hospitalist “value” went up because of lower costs.

But an interesting thing changed over the past decade: It seems that fewer and fewer people are talking about hospitalists reducing LOS. They just expect it. LOS is raised as an issue only if it goes up. In many hospitals, the budget now takes into account the average LOS based on hospitalist care. (I suspect that in 18th-century Scotland, people also grew accustomed to the lower cost of pins, and grew to expect it, and the cost of pins was raised as an issue only if the price went up.)

But has anyone spoken to the hospitalists? Has anyone asked us about the benefits of our profession? Many of the hospitalists I meet mention “reduction of length of stay” as a main reason to have hospitalists. I think that response was appropriate more often than not over the past 15 years.

But today, ask any hospital administrator that same question, and what do you expect the answer to be? It should not be surprising to hospitalists that most hospitals expect much more from their hospitalist programs than “just reducing the length of stay.” These are the same hospitals that often support—to the tune of more than $100,000 per hospitalist full-time equivalent—your HM program. If your hospitalist program is anything like mine at Beth Israel Deaconess Medical Center in Boston, this represents millions of dollars to the hospitalist program budget.

Increased Pressures

The fact that hospitals’ expectations of hospitalists have changed should not come as a surprise. Americans’ expectations of hospitals have changed markedly over the past 15 years. In the 1990s, when hospital medicine was “born,” there was little mention of quality and patient satisfaction when it came to healthcare. Who would argue that improving quality and patient satisfaction is a bad thing?

Over the past decade, we’ve seen the development of Medicare core measures and the link between patient outcomes and Medicare reimbursement. Hospitals could not have achieved many of their performance improvements without their partnerships with hospitalists.

Hospitals are under increasing pressure to not only decrease costs, but also improve quality. It is understandable that they turn to the “inpatient specialists”—the hospitalists—to help them meet societal expectations. But as hospitalists, this puts pressure on us to continually improve our game—or face the consequences. A pin factory in Scotland can only survive if it produces higher-quality pins at a lower cost than its competitor.

Hospitals and our American healthcare system expect much more today from hospitalists, and they should; patients’ lives are at stake. It should not be a surprise that hospitalist programs that struggle are those that fail to meet expectations. Successful hospitalist programs, the ones that are able to demonstrate their “value,” do so well beyond knowing their patient’s average length of stay.

I am interested in learning about your efforts to demonstrate the “value” of your hospitalist group. Feel free to email me at JosephLi@hospitalmedicine.org.

Dr. Li is president of SHM.

For those of you who were kind enough to pick up my column in The Hospitalist last month (see “A Critical First Step,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system to purchase healthcare and that all healthcare providers, including hospitalists, will be increasingly judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality÷cost.)

I believe that the hospitalist programs that are going to be the most successful are those that are able to continually measure their quality and costs, allowing them to make improvements. These are the groups that will understand their own performance well before others make their “value” judgments.

History Lesson

In his famous book “The Wealth of Nations,” 18th-century economist Adam Smith used the example of a pin factory to show how specialization improved human productivity. The process of producing a pin was broken down into many small tasks, each done by a different “specialist.” This resulted not only in increased efficiency, but also increased productivity. The factory was then able to reinvest the profits in even more efficient machinery, which was able to reduce labor costs. The lower cost for pins was a benefit, and it was spread across the entire population.

We have seen similar examples in American healthcare. In many American hospitals, the images of CT scans performed during nighttime hours are transmitted to India and other Asian countries where highly trained radiologists interpret the scans and transmit their interpretations back to the physicians caring for the patients. Like the pin factory workers, these radiologists are specialists with unique skills; they operate specialized machinery to make the system more efficient with resultant lower costs. At the level of the individual patient, this system means getting test results back in a more timely fashion. Increased quality and lower costs: These are high-value providers.

It should be obvious to us that hospitalists are “specialists.” While most hospitalists are trained as general internists, pediatricians, and family physicians, you and I are “specialists” who focus our efforts on the care of hospitalized patients. In the late 1990s, much was made of the fact that hospitalists were able to reduce hospital costs because of decreased length of stay (LOS) for patients, without any adverse effects on clinical outcomes. Today, hospitalists number more than 30,000 nationwide, and virtually all American hospitals with more than 200 beds have hospitalists.

Hospitals hired hospitalists in droves because they were perceived as “inpatient specialists” who were able to reduce the cost of healthcare delivery. Like lower pin costs, this economic benefit was spread across the entire population. Hospitalist “value” went up because of lower costs.

But an interesting thing changed over the past decade: It seems that fewer and fewer people are talking about hospitalists reducing LOS. They just expect it. LOS is raised as an issue only if it goes up. In many hospitals, the budget now takes into account the average LOS based on hospitalist care. (I suspect that in 18th-century Scotland, people also grew accustomed to the lower cost of pins, and grew to expect it, and the cost of pins was raised as an issue only if the price went up.)

But has anyone spoken to the hospitalists? Has anyone asked us about the benefits of our profession? Many of the hospitalists I meet mention “reduction of length of stay” as a main reason to have hospitalists. I think that response was appropriate more often than not over the past 15 years.

But today, ask any hospital administrator that same question, and what do you expect the answer to be? It should not be surprising to hospitalists that most hospitals expect much more from their hospitalist programs than “just reducing the length of stay.” These are the same hospitals that often support—to the tune of more than $100,000 per hospitalist full-time equivalent—your HM program. If your hospitalist program is anything like mine at Beth Israel Deaconess Medical Center in Boston, this represents millions of dollars to the hospitalist program budget.

Increased Pressures

The fact that hospitals’ expectations of hospitalists have changed should not come as a surprise. Americans’ expectations of hospitals have changed markedly over the past 15 years. In the 1990s, when hospital medicine was “born,” there was little mention of quality and patient satisfaction when it came to healthcare. Who would argue that improving quality and patient satisfaction is a bad thing?

Over the past decade, we’ve seen the development of Medicare core measures and the link between patient outcomes and Medicare reimbursement. Hospitals could not have achieved many of their performance improvements without their partnerships with hospitalists.

Hospitals are under increasing pressure to not only decrease costs, but also improve quality. It is understandable that they turn to the “inpatient specialists”—the hospitalists—to help them meet societal expectations. But as hospitalists, this puts pressure on us to continually improve our game—or face the consequences. A pin factory in Scotland can only survive if it produces higher-quality pins at a lower cost than its competitor.

Hospitals and our American healthcare system expect much more today from hospitalists, and they should; patients’ lives are at stake. It should not be a surprise that hospitalist programs that struggle are those that fail to meet expectations. Successful hospitalist programs, the ones that are able to demonstrate their “value,” do so well beyond knowing their patient’s average length of stay.

I am interested in learning about your efforts to demonstrate the “value” of your hospitalist group. Feel free to email me at JosephLi@hospitalmedicine.org.

Dr. Li is president of SHM.

For those of you who were kind enough to pick up my column in The Hospitalist last month (see “A Critical First Step,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system to purchase healthcare and that all healthcare providers, including hospitalists, will be increasingly judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality÷cost.)

I believe that the hospitalist programs that are going to be the most successful are those that are able to continually measure their quality and costs, allowing them to make improvements. These are the groups that will understand their own performance well before others make their “value” judgments.

History Lesson

In his famous book “The Wealth of Nations,” 18th-century economist Adam Smith used the example of a pin factory to show how specialization improved human productivity. The process of producing a pin was broken down into many small tasks, each done by a different “specialist.” This resulted not only in increased efficiency, but also increased productivity. The factory was then able to reinvest the profits in even more efficient machinery, which was able to reduce labor costs. The lower cost for pins was a benefit, and it was spread across the entire population.

We have seen similar examples in American healthcare. In many American hospitals, the images of CT scans performed during nighttime hours are transmitted to India and other Asian countries where highly trained radiologists interpret the scans and transmit their interpretations back to the physicians caring for the patients. Like the pin factory workers, these radiologists are specialists with unique skills; they operate specialized machinery to make the system more efficient with resultant lower costs. At the level of the individual patient, this system means getting test results back in a more timely fashion. Increased quality and lower costs: These are high-value providers.

It should be obvious to us that hospitalists are “specialists.” While most hospitalists are trained as general internists, pediatricians, and family physicians, you and I are “specialists” who focus our efforts on the care of hospitalized patients. In the late 1990s, much was made of the fact that hospitalists were able to reduce hospital costs because of decreased length of stay (LOS) for patients, without any adverse effects on clinical outcomes. Today, hospitalists number more than 30,000 nationwide, and virtually all American hospitals with more than 200 beds have hospitalists.

Hospitals hired hospitalists in droves because they were perceived as “inpatient specialists” who were able to reduce the cost of healthcare delivery. Like lower pin costs, this economic benefit was spread across the entire population. Hospitalist “value” went up because of lower costs.

But an interesting thing changed over the past decade: It seems that fewer and fewer people are talking about hospitalists reducing LOS. They just expect it. LOS is raised as an issue only if it goes up. In many hospitals, the budget now takes into account the average LOS based on hospitalist care. (I suspect that in 18th-century Scotland, people also grew accustomed to the lower cost of pins, and grew to expect it, and the cost of pins was raised as an issue only if the price went up.)

But has anyone spoken to the hospitalists? Has anyone asked us about the benefits of our profession? Many of the hospitalists I meet mention “reduction of length of stay” as a main reason to have hospitalists. I think that response was appropriate more often than not over the past 15 years.

But today, ask any hospital administrator that same question, and what do you expect the answer to be? It should not be surprising to hospitalists that most hospitals expect much more from their hospitalist programs than “just reducing the length of stay.” These are the same hospitals that often support—to the tune of more than $100,000 per hospitalist full-time equivalent—your HM program. If your hospitalist program is anything like mine at Beth Israel Deaconess Medical Center in Boston, this represents millions of dollars to the hospitalist program budget.

Increased Pressures

The fact that hospitals’ expectations of hospitalists have changed should not come as a surprise. Americans’ expectations of hospitals have changed markedly over the past 15 years. In the 1990s, when hospital medicine was “born,” there was little mention of quality and patient satisfaction when it came to healthcare. Who would argue that improving quality and patient satisfaction is a bad thing?

Over the past decade, we’ve seen the development of Medicare core measures and the link between patient outcomes and Medicare reimbursement. Hospitals could not have achieved many of their performance improvements without their partnerships with hospitalists.

Hospitals are under increasing pressure to not only decrease costs, but also improve quality. It is understandable that they turn to the “inpatient specialists”—the hospitalists—to help them meet societal expectations. But as hospitalists, this puts pressure on us to continually improve our game—or face the consequences. A pin factory in Scotland can only survive if it produces higher-quality pins at a lower cost than its competitor.

Hospitals and our American healthcare system expect much more today from hospitalists, and they should; patients’ lives are at stake. It should not be a surprise that hospitalist programs that struggle are those that fail to meet expectations. Successful hospitalist programs, the ones that are able to demonstrate their “value,” do so well beyond knowing their patient’s average length of stay.

I am interested in learning about your efforts to demonstrate the “value” of your hospitalist group. Feel free to email me at JosephLi@hospitalmedicine.org.

Dr. Li is president of SHM.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at JosephLi@HospitalMedicine.org.

Dr. Li is president of SHM.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at JosephLi@HospitalMedicine.org.

Dr. Li is president of SHM.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at JosephLi@HospitalMedicine.org.

Dr. Li is president of SHM.

My name is Joe Li, MD, SFHM. I am a hospitalist who works at Beth Israel Deaconess Medical Center in Boston. I have the privilege of serving as the SHM president for the upcoming year. I thank each of you for entrusting me with this important role.

Given the trust you have shared with me, I think it is only fair that I tell you a little bit about myself. For the “birthers” in the crowd, your fears have been realized. I was not born in this country; I was not even born in Panama. Not only were my parents immigrants—like many of you or your ancestors—I am also an immigrant to this country.

While I live now in Boston, I did not grow up there. Like many of you, I grew up in the middle part of the country. Like our immediate past president, Jeff Wiese, MD, SFHM, I spent my formative years in Oklahoma. My parents were not poor, but they were far from wealthy. Like most of you, I grew up in middle-class America.

Although I now have a teaching appointment at Harvard Medical School, neither my parents nor I ever paid tuition at a private school. Like many of you, I received my schooling at a public university.

I completed my undergraduate and medical school studies at the University of Oklahoma, and I moved to Boston for my post-graduate training. In fact, I was the first hospitalist at Beth Israel Deaconess Medical Center in 1998.

I joined the National Association of Inpatient Physicians (now SHM) as a charter member, and what I have learned from spending time with many of you over the years is that my story is not unique—there is tremendous diversity throughout SHM, but we are held together by the shared vision of improving care for our hospitalized patients.

For those of you new to SHM, I want to make it clear that SHM is not run by the president but by its collective members. Yes, we do have an organizational structure, with an elected board of directors and an elected executive committee made up of the president-elect, the president, the immediate past president, and the CEO. This past year, I served as the president-elect and had the wonderful opportunity of working with Dr. Wiese, our immediate past president, Scott Flanders, MD, SFHM, and our CEO, Larry Wellikson, MD, SFHM.

I can tell you firsthand about the tireless work that each of these physicians puts in to serve our patients and our profession. Each is an incredible leader, and I thank them, as well as our board of directors and SHM staff members, for all the work they put in to keep our organization running smoothly. While their work is not obvious day to day, there are many others who serve our organization in an invisible role. These include our committee leaders and committee members. I also thank you for all of your hard work for SHM and for our profession.

Despite all the hard work that has been done, there is still so much to do. I am personally asking each one of you to serve HM in your own way. Being an SHM member and attending SHM meetings are ways of serving, but I challenge each of you to do more. For some of you, it could be setting an expectation that all of your hospitalists join SHM and attend SHM meetings. For others, it could be helping to organize and lead your local chapters.

There is a role for each of us in HM, and I believe strongly that if we are to improve the care of our patients, each of us must take responsibility by serving our profession. There is no role too small. Each one of us must lead in our own way.

I look forward to the opportunity this year of speaking with each of you, not only as I travel the country to the various SHM meetings and chapter events, but also through this monthly column. I hope to share with you my observations of the happenings throughout hospital medicine. I expect to see and hear remarkable work being done by hospitalists across the country in our continued effort to bring increasing healthcare value to our patients. TH

Dr. Li is president of SHM, associate professor of medicine at Harvard Medical School in Boston, and director of the hospital medicine program and associate chief of the division of general medicine and primary care at Beth Israel Deaconess Medical Center.

My name is Joe Li, MD, SFHM. I am a hospitalist who works at Beth Israel Deaconess Medical Center in Boston. I have the privilege of serving as the SHM president for the upcoming year. I thank each of you for entrusting me with this important role.

Given the trust you have shared with me, I think it is only fair that I tell you a little bit about myself. For the “birthers” in the crowd, your fears have been realized. I was not born in this country; I was not even born in Panama. Not only were my parents immigrants—like many of you or your ancestors—I am also an immigrant to this country.

While I live now in Boston, I did not grow up there. Like many of you, I grew up in the middle part of the country. Like our immediate past president, Jeff Wiese, MD, SFHM, I spent my formative years in Oklahoma. My parents were not poor, but they were far from wealthy. Like most of you, I grew up in middle-class America.

Although I now have a teaching appointment at Harvard Medical School, neither my parents nor I ever paid tuition at a private school. Like many of you, I received my schooling at a public university.

I completed my undergraduate and medical school studies at the University of Oklahoma, and I moved to Boston for my post-graduate training. In fact, I was the first hospitalist at Beth Israel Deaconess Medical Center in 1998.

I joined the National Association of Inpatient Physicians (now SHM) as a charter member, and what I have learned from spending time with many of you over the years is that my story is not unique—there is tremendous diversity throughout SHM, but we are held together by the shared vision of improving care for our hospitalized patients.

For those of you new to SHM, I want to make it clear that SHM is not run by the president but by its collective members. Yes, we do have an organizational structure, with an elected board of directors and an elected executive committee made up of the president-elect, the president, the immediate past president, and the CEO. This past year, I served as the president-elect and had the wonderful opportunity of working with Dr. Wiese, our immediate past president, Scott Flanders, MD, SFHM, and our CEO, Larry Wellikson, MD, SFHM.

I can tell you firsthand about the tireless work that each of these physicians puts in to serve our patients and our profession. Each is an incredible leader, and I thank them, as well as our board of directors and SHM staff members, for all the work they put in to keep our organization running smoothly. While their work is not obvious day to day, there are many others who serve our organization in an invisible role. These include our committee leaders and committee members. I also thank you for all of your hard work for SHM and for our profession.

Despite all the hard work that has been done, there is still so much to do. I am personally asking each one of you to serve HM in your own way. Being an SHM member and attending SHM meetings are ways of serving, but I challenge each of you to do more. For some of you, it could be setting an expectation that all of your hospitalists join SHM and attend SHM meetings. For others, it could be helping to organize and lead your local chapters.

There is a role for each of us in HM, and I believe strongly that if we are to improve the care of our patients, each of us must take responsibility by serving our profession. There is no role too small. Each one of us must lead in our own way.

I look forward to the opportunity this year of speaking with each of you, not only as I travel the country to the various SHM meetings and chapter events, but also through this monthly column. I hope to share with you my observations of the happenings throughout hospital medicine. I expect to see and hear remarkable work being done by hospitalists across the country in our continued effort to bring increasing healthcare value to our patients. TH

Dr. Li is president of SHM, associate professor of medicine at Harvard Medical School in Boston, and director of the hospital medicine program and associate chief of the division of general medicine and primary care at Beth Israel Deaconess Medical Center.

My name is Joe Li, MD, SFHM. I am a hospitalist who works at Beth Israel Deaconess Medical Center in Boston. I have the privilege of serving as the SHM president for the upcoming year. I thank each of you for entrusting me with this important role.

Given the trust you have shared with me, I think it is only fair that I tell you a little bit about myself. For the “birthers” in the crowd, your fears have been realized. I was not born in this country; I was not even born in Panama. Not only were my parents immigrants—like many of you or your ancestors—I am also an immigrant to this country.

While I live now in Boston, I did not grow up there. Like many of you, I grew up in the middle part of the country. Like our immediate past president, Jeff Wiese, MD, SFHM, I spent my formative years in Oklahoma. My parents were not poor, but they were far from wealthy. Like most of you, I grew up in middle-class America.

Although I now have a teaching appointment at Harvard Medical School, neither my parents nor I ever paid tuition at a private school. Like many of you, I received my schooling at a public university.

I completed my undergraduate and medical school studies at the University of Oklahoma, and I moved to Boston for my post-graduate training. In fact, I was the first hospitalist at Beth Israel Deaconess Medical Center in 1998.

I joined the National Association of Inpatient Physicians (now SHM) as a charter member, and what I have learned from spending time with many of you over the years is that my story is not unique—there is tremendous diversity throughout SHM, but we are held together by the shared vision of improving care for our hospitalized patients.

For those of you new to SHM, I want to make it clear that SHM is not run by the president but by its collective members. Yes, we do have an organizational structure, with an elected board of directors and an elected executive committee made up of the president-elect, the president, the immediate past president, and the CEO. This past year, I served as the president-elect and had the wonderful opportunity of working with Dr. Wiese, our immediate past president, Scott Flanders, MD, SFHM, and our CEO, Larry Wellikson, MD, SFHM.

I can tell you firsthand about the tireless work that each of these physicians puts in to serve our patients and our profession. Each is an incredible leader, and I thank them, as well as our board of directors and SHM staff members, for all the work they put in to keep our organization running smoothly. While their work is not obvious day to day, there are many others who serve our organization in an invisible role. These include our committee leaders and committee members. I also thank you for all of your hard work for SHM and for our profession.

Despite all the hard work that has been done, there is still so much to do. I am personally asking each one of you to serve HM in your own way. Being an SHM member and attending SHM meetings are ways of serving, but I challenge each of you to do more. For some of you, it could be setting an expectation that all of your hospitalists join SHM and attend SHM meetings. For others, it could be helping to organize and lead your local chapters.

There is a role for each of us in HM, and I believe strongly that if we are to improve the care of our patients, each of us must take responsibility by serving our profession. There is no role too small. Each one of us must lead in our own way.

I look forward to the opportunity this year of speaking with each of you, not only as I travel the country to the various SHM meetings and chapter events, but also through this monthly column. I hope to share with you my observations of the happenings throughout hospital medicine. I expect to see and hear remarkable work being done by hospitalists across the country in our continued effort to bring increasing healthcare value to our patients. TH

Dr. Li is president of SHM, associate professor of medicine at Harvard Medical School in Boston, and director of the hospital medicine program and associate chief of the division of general medicine and primary care at Beth Israel Deaconess Medical Center.