Larry Wellikson, MD, FACP

One of the interesting things about hospital medicine is our diversity. It is an evolutionary construct and can be both a strength and a concern as we all try to create and define our new specialty.

Most hospitalists are trained as general internists. This wasn’t always so. As recently as 1997 almost 50% of hospitalists were internal medical subspecialists. The thinking at that time was that because infectious disease docs, pulmonologists, intensivists, and others were already in the hospital seeing ill patients, why couldn’t they just also be hospitalists?

Well, it turned out they wanted to be infectious disease specialists and pulmonologists and they soon found out that being a hospitalist is somewhat different than these other specialties.

Now hospital medicine is a popular career path for those finishing a general internal medicine residency, as well as for those who are finding a career as a hospitalist preferable to their original choice as in traditional internal medicine. (See “Trendwatch: The Specialization of Hospital Medicine,” p. 27.)

PEDIATRICIANS AND FAMILY PRACTICE

At the same time, even though only 3% of hospitalists are family practitioners, more than 90% of hospitalists in Canada come out of family practice training. Increasingly, young graduates of family practice residency programs are choosing to become hospitalists.

And let’s not forget the pediatricians. Pediatricians comprise about 9% of all hospitalists, and more than 200 pediatric hospitalists got together for the largest pediatric hospital medicine meeting ever in Denver at the end of July. (See the “Pediatric Special Section,” p. 33.) It was an impressive community of pediatric hospitalists. Most children’s hospitals and many community hospitals now have pediatric hospital medicine groups. Most of the pediatric inpatient care in this country is now provided by hospitalists and pediatric subspecialists.

In fact, those who have taken training in med-peds are finding that a career as a hospitalist is a nice fit, and they are welcomed by those who care for children and adults in the hospital.

But hospital medicine is not only about physician caregivers. More than 5% of hospitalists in this country are nonphysician providers, either nurse practitioners or physician assistants. As the demand for hospitalists rapidly increases many hospital medicine groups find that adding nurse practitioners or physician assistants helps them to complete the workforce they need to have in place to meet their clinical and administrative demands.

And hospital medicine includes pharmacists, case managers, and administrators to round out the inpatient team. Each of these professions is developing “hospital medicine specialists” looking for skills and experiences to allow them to help facilitate the work of the hospitalists and to use a team approach to achieve the rapidly expanded expectations of hospital medicine groups.

EDUCATION AND CERTIFICATION ISSUES

This growing conglomeration of healthcare professionals in one specialty presents unique issues. Some of these come in the form of diverse and expanding educational needs. The patient wants to be assured that no matter where the individual hospitalist started his or her training, the hospitalist will bring to the bedside the appropriate skills for their acute medical problems. This leads to having SHM develop courses in critical care skills, perioperative medicine, leadership, and the like.

Yet even though the endpoint may need to be similar for all hospitalists, it takes a fine touch and significant customization to craft educational materials when many hospitalists may start from a different base point.

When it comes to potential credentialing in hospital medicine, there is not a clear path to create a certification in hospital medicine. The solution for the 80% of hospitalists trained in internal medicine may very well be through the American Board of Internal Medicine (ABIM), but the pediatric and family practice solution will need to involve the American Board of Pediatrics (ABP) and the American Board of Family Medicine (ABFP), respectively. And this doesn’t even begin to address the credentialing needs of the nonphysicians.

Further, as SHM looks to represent all of the diverse elements that form the fabric of hospital medicine, we need to be in touch with the American College of Physicians, the American Academy of Pediatrics, the American Academy of Family Physicians, the Society of General Internal Medicine, the Ambulatory Pediatric Association, the American Association of Critical Care Nurses, the American Society of Health System Pharmacists, the American

Academy of Physicians Assistants, the American Academy of Nurse Practitioners, and many other important substantial medical professional societies; members of each believe that their organization relates to a segment of hospital medicine.

DIVERSITY CREATES NEW SOLUTIONS

The good part of this diversity is that as SHM helps to build this new specialty we are able to include so many unique vantage points. This strategy of inclusion allows for new ideas to percolate to the surface and leads to innovation and creativity. In fashioning the hospital of the future, “old think” must not rule the day. One way to change the outcome is to change those who are at the table.

If hospital medicine is to be part of the process of creating a hospital that is patient-centered, relies on measurable quality improvement, and delivers care by teams of healthcare professionals, then we need to open the tent and let in different perspectives. In SHM’s ongoing quality improvement efforts in heart failure and glycemic control, this is our approach—with meaningful input from hospitalists, subspecialists, nurses, pharmacists, and many other stakeholders in hospital medicine. This will lead to a different and—let’s hope—better outcome.

LABORISTS AND SURGICALISTS

And there are more wrinkles in the hospitalist world all the time. Recently USA Today wrote a story about “laborists” as hospitals try to solve access to obstetrical services by having contracted laborists on site 24/7. Some hospitals have to be creative when their community surgeons aren’t available for trauma care and some hospitals have contracted with orthopedists and general surgeons as “surgicalists.”

Are these the latest additions to the roll call of hospital medicine or just a footnote or an asterisk? Time and the marketplace will tell.

Besides the basic training for hospitalists there are many variations determined by site of practice and employment model. Whether we are talking about the differences between academic

hospital medicine or that practiced in community hospitals, or the uniqueness of a small group of hospitalists at only one hospital or a large multistate group of hospitalists in 10 states with 400 hospitalists, we are all part of hospital medicine.

In the end, hospital medicine is defined more by its common goals and its common values regardless of initial training or mode of practice. At this time in healthcare, many are looking for healthcare professionals to have the skills and the energy to create the hospital

of the future that will be a better place to work and to get the best care. SHM is committed to harnessing the diversity of our specialty to do our part to create a better future. With your help, we can get there. TH

Dr. Wellikson has been the CEO of SHM since 2000.

One of the interesting things about hospital medicine is our diversity. It is an evolutionary construct and can be both a strength and a concern as we all try to create and define our new specialty.

Most hospitalists are trained as general internists. This wasn’t always so. As recently as 1997 almost 50% of hospitalists were internal medical subspecialists. The thinking at that time was that because infectious disease docs, pulmonologists, intensivists, and others were already in the hospital seeing ill patients, why couldn’t they just also be hospitalists?

Well, it turned out they wanted to be infectious disease specialists and pulmonologists and they soon found out that being a hospitalist is somewhat different than these other specialties.

Now hospital medicine is a popular career path for those finishing a general internal medicine residency, as well as for those who are finding a career as a hospitalist preferable to their original choice as in traditional internal medicine. (See “Trendwatch: The Specialization of Hospital Medicine,” p. 27.)

PEDIATRICIANS AND FAMILY PRACTICE

At the same time, even though only 3% of hospitalists are family practitioners, more than 90% of hospitalists in Canada come out of family practice training. Increasingly, young graduates of family practice residency programs are choosing to become hospitalists.

And let’s not forget the pediatricians. Pediatricians comprise about 9% of all hospitalists, and more than 200 pediatric hospitalists got together for the largest pediatric hospital medicine meeting ever in Denver at the end of July. (See the “Pediatric Special Section,” p. 33.) It was an impressive community of pediatric hospitalists. Most children’s hospitals and many community hospitals now have pediatric hospital medicine groups. Most of the pediatric inpatient care in this country is now provided by hospitalists and pediatric subspecialists.

In fact, those who have taken training in med-peds are finding that a career as a hospitalist is a nice fit, and they are welcomed by those who care for children and adults in the hospital.

But hospital medicine is not only about physician caregivers. More than 5% of hospitalists in this country are nonphysician providers, either nurse practitioners or physician assistants. As the demand for hospitalists rapidly increases many hospital medicine groups find that adding nurse practitioners or physician assistants helps them to complete the workforce they need to have in place to meet their clinical and administrative demands.

And hospital medicine includes pharmacists, case managers, and administrators to round out the inpatient team. Each of these professions is developing “hospital medicine specialists” looking for skills and experiences to allow them to help facilitate the work of the hospitalists and to use a team approach to achieve the rapidly expanded expectations of hospital medicine groups.

EDUCATION AND CERTIFICATION ISSUES

This growing conglomeration of healthcare professionals in one specialty presents unique issues. Some of these come in the form of diverse and expanding educational needs. The patient wants to be assured that no matter where the individual hospitalist started his or her training, the hospitalist will bring to the bedside the appropriate skills for their acute medical problems. This leads to having SHM develop courses in critical care skills, perioperative medicine, leadership, and the like.

Yet even though the endpoint may need to be similar for all hospitalists, it takes a fine touch and significant customization to craft educational materials when many hospitalists may start from a different base point.

When it comes to potential credentialing in hospital medicine, there is not a clear path to create a certification in hospital medicine. The solution for the 80% of hospitalists trained in internal medicine may very well be through the American Board of Internal Medicine (ABIM), but the pediatric and family practice solution will need to involve the American Board of Pediatrics (ABP) and the American Board of Family Medicine (ABFP), respectively. And this doesn’t even begin to address the credentialing needs of the nonphysicians.

Further, as SHM looks to represent all of the diverse elements that form the fabric of hospital medicine, we need to be in touch with the American College of Physicians, the American Academy of Pediatrics, the American Academy of Family Physicians, the Society of General Internal Medicine, the Ambulatory Pediatric Association, the American Association of Critical Care Nurses, the American Society of Health System Pharmacists, the American

Academy of Physicians Assistants, the American Academy of Nurse Practitioners, and many other important substantial medical professional societies; members of each believe that their organization relates to a segment of hospital medicine.

DIVERSITY CREATES NEW SOLUTIONS

The good part of this diversity is that as SHM helps to build this new specialty we are able to include so many unique vantage points. This strategy of inclusion allows for new ideas to percolate to the surface and leads to innovation and creativity. In fashioning the hospital of the future, “old think” must not rule the day. One way to change the outcome is to change those who are at the table.

If hospital medicine is to be part of the process of creating a hospital that is patient-centered, relies on measurable quality improvement, and delivers care by teams of healthcare professionals, then we need to open the tent and let in different perspectives. In SHM’s ongoing quality improvement efforts in heart failure and glycemic control, this is our approach—with meaningful input from hospitalists, subspecialists, nurses, pharmacists, and many other stakeholders in hospital medicine. This will lead to a different and—let’s hope—better outcome.

LABORISTS AND SURGICALISTS

And there are more wrinkles in the hospitalist world all the time. Recently USA Today wrote a story about “laborists” as hospitals try to solve access to obstetrical services by having contracted laborists on site 24/7. Some hospitals have to be creative when their community surgeons aren’t available for trauma care and some hospitals have contracted with orthopedists and general surgeons as “surgicalists.”

Are these the latest additions to the roll call of hospital medicine or just a footnote or an asterisk? Time and the marketplace will tell.

Besides the basic training for hospitalists there are many variations determined by site of practice and employment model. Whether we are talking about the differences between academic

hospital medicine or that practiced in community hospitals, or the uniqueness of a small group of hospitalists at only one hospital or a large multistate group of hospitalists in 10 states with 400 hospitalists, we are all part of hospital medicine.

In the end, hospital medicine is defined more by its common goals and its common values regardless of initial training or mode of practice. At this time in healthcare, many are looking for healthcare professionals to have the skills and the energy to create the hospital

of the future that will be a better place to work and to get the best care. SHM is committed to harnessing the diversity of our specialty to do our part to create a better future. With your help, we can get there. TH

Dr. Wellikson has been the CEO of SHM since 2000.

One of the interesting things about hospital medicine is our diversity. It is an evolutionary construct and can be both a strength and a concern as we all try to create and define our new specialty.

Most hospitalists are trained as general internists. This wasn’t always so. As recently as 1997 almost 50% of hospitalists were internal medical subspecialists. The thinking at that time was that because infectious disease docs, pulmonologists, intensivists, and others were already in the hospital seeing ill patients, why couldn’t they just also be hospitalists?

Well, it turned out they wanted to be infectious disease specialists and pulmonologists and they soon found out that being a hospitalist is somewhat different than these other specialties.

Now hospital medicine is a popular career path for those finishing a general internal medicine residency, as well as for those who are finding a career as a hospitalist preferable to their original choice as in traditional internal medicine. (See “Trendwatch: The Specialization of Hospital Medicine,” p. 27.)

PEDIATRICIANS AND FAMILY PRACTICE

At the same time, even though only 3% of hospitalists are family practitioners, more than 90% of hospitalists in Canada come out of family practice training. Increasingly, young graduates of family practice residency programs are choosing to become hospitalists.

And let’s not forget the pediatricians. Pediatricians comprise about 9% of all hospitalists, and more than 200 pediatric hospitalists got together for the largest pediatric hospital medicine meeting ever in Denver at the end of July. (See the “Pediatric Special Section,” p. 33.) It was an impressive community of pediatric hospitalists. Most children’s hospitals and many community hospitals now have pediatric hospital medicine groups. Most of the pediatric inpatient care in this country is now provided by hospitalists and pediatric subspecialists.

In fact, those who have taken training in med-peds are finding that a career as a hospitalist is a nice fit, and they are welcomed by those who care for children and adults in the hospital.

But hospital medicine is not only about physician caregivers. More than 5% of hospitalists in this country are nonphysician providers, either nurse practitioners or physician assistants. As the demand for hospitalists rapidly increases many hospital medicine groups find that adding nurse practitioners or physician assistants helps them to complete the workforce they need to have in place to meet their clinical and administrative demands.

And hospital medicine includes pharmacists, case managers, and administrators to round out the inpatient team. Each of these professions is developing “hospital medicine specialists” looking for skills and experiences to allow them to help facilitate the work of the hospitalists and to use a team approach to achieve the rapidly expanded expectations of hospital medicine groups.

EDUCATION AND CERTIFICATION ISSUES

This growing conglomeration of healthcare professionals in one specialty presents unique issues. Some of these come in the form of diverse and expanding educational needs. The patient wants to be assured that no matter where the individual hospitalist started his or her training, the hospitalist will bring to the bedside the appropriate skills for their acute medical problems. This leads to having SHM develop courses in critical care skills, perioperative medicine, leadership, and the like.

Yet even though the endpoint may need to be similar for all hospitalists, it takes a fine touch and significant customization to craft educational materials when many hospitalists may start from a different base point.

When it comes to potential credentialing in hospital medicine, there is not a clear path to create a certification in hospital medicine. The solution for the 80% of hospitalists trained in internal medicine may very well be through the American Board of Internal Medicine (ABIM), but the pediatric and family practice solution will need to involve the American Board of Pediatrics (ABP) and the American Board of Family Medicine (ABFP), respectively. And this doesn’t even begin to address the credentialing needs of the nonphysicians.

Further, as SHM looks to represent all of the diverse elements that form the fabric of hospital medicine, we need to be in touch with the American College of Physicians, the American Academy of Pediatrics, the American Academy of Family Physicians, the Society of General Internal Medicine, the Ambulatory Pediatric Association, the American Association of Critical Care Nurses, the American Society of Health System Pharmacists, the American

Academy of Physicians Assistants, the American Academy of Nurse Practitioners, and many other important substantial medical professional societies; members of each believe that their organization relates to a segment of hospital medicine.

DIVERSITY CREATES NEW SOLUTIONS

The good part of this diversity is that as SHM helps to build this new specialty we are able to include so many unique vantage points. This strategy of inclusion allows for new ideas to percolate to the surface and leads to innovation and creativity. In fashioning the hospital of the future, “old think” must not rule the day. One way to change the outcome is to change those who are at the table.

If hospital medicine is to be part of the process of creating a hospital that is patient-centered, relies on measurable quality improvement, and delivers care by teams of healthcare professionals, then we need to open the tent and let in different perspectives. In SHM’s ongoing quality improvement efforts in heart failure and glycemic control, this is our approach—with meaningful input from hospitalists, subspecialists, nurses, pharmacists, and many other stakeholders in hospital medicine. This will lead to a different and—let’s hope—better outcome.

LABORISTS AND SURGICALISTS

And there are more wrinkles in the hospitalist world all the time. Recently USA Today wrote a story about “laborists” as hospitals try to solve access to obstetrical services by having contracted laborists on site 24/7. Some hospitals have to be creative when their community surgeons aren’t available for trauma care and some hospitals have contracted with orthopedists and general surgeons as “surgicalists.”

Are these the latest additions to the roll call of hospital medicine or just a footnote or an asterisk? Time and the marketplace will tell.

Besides the basic training for hospitalists there are many variations determined by site of practice and employment model. Whether we are talking about the differences between academic

hospital medicine or that practiced in community hospitals, or the uniqueness of a small group of hospitalists at only one hospital or a large multistate group of hospitalists in 10 states with 400 hospitalists, we are all part of hospital medicine.

In the end, hospital medicine is defined more by its common goals and its common values regardless of initial training or mode of practice. At this time in healthcare, many are looking for healthcare professionals to have the skills and the energy to create the hospital

of the future that will be a better place to work and to get the best care. SHM is committed to harnessing the diversity of our specialty to do our part to create a better future. With your help, we can get there. TH

Dr. Wellikson has been the CEO of SHM since 2000.

A few months ago SHM received an e-mail from SHM member Jennifer Bellino, MD, a hospitalist at William Backus Hospital in Norwich, Conn. She had gotten wind of a proposal flowing through the Public Health Committee at the Connecticut State Legislature that would mandate the frequency of communications between hospitalists and primary care physicians (PCPs). From her short e-mail SHM’s advocacy enterprise sprung into action.

Bill 5721 was being introduced to the Public Health Committee in the Connecticut Legislature, and it required the development of state regulations that would have governed the timing and frequency of communications between hospitalists and PCPs.

Laura Allendorf, SHM’s head of Governmental Affairs, engaged SHM’s Public Policy Committee to better understand the issues involved in this bill and to get a sense of whether this was a unique bill for Connecticut or whether it was being introduced in other state legislatures.

While the bill appeared to be isolated to Connecticut, the Public Policy Committee thought the issue was threatening enough to the practice of hospital medicine that local aggressive action was necessary.

Allendorf contacted the Connecticut State Medical Society and spoke to Ken Ferrucci, director of government relations, who was already aware of Bill 5721. The Connecticut State Medical Society (CSMS) was opposed to the bill as well, and Ferrucci proposed that SHM find a Connecticut hospitalist who could come to Hartford to speak against Bill 5721 at the Public Health Committee, which would hear testimony in just a few days.

Unfortunately, no one on the Public Policy Committee was from Connecticut. Fortunately, SHM was familiar with Bill Rifkin, MD, from Yale (New Haven) and Waterbury Hospital, who is active at SHM as a member of our Education Committee. Allendorf contacted Dr. Rifkin and explained the situation. He dropped everything on his calendar and changed his appointments and agreed to come to Hartford to fly the SHM banner and testify before the Public Health Committee.

Working together Allendorf, Eric Siegal, the Public Policy committee chair, and Dr. Rifkin crafted the testimony necessary to explain to the legislators just what hospital medicine is and what hospitalists do. In addition, they emphasized that hospitalists are working hard to be the experts in transitions of care and that mandates and regulations were not needed and, in fact, could be detrimental to the fundamental relationship between PCPs and hospitalists.

SHM then coordinated our approach with that of the Connecticut State Medical Society to create a unified front for maximum effectiveness. In the end Dr. Rifkin carried the day.

After Dr. Rifkin’s testimony, as well as testimony from the Connecticut State Medical Society, the bill died a quiet death. Eventually, a watered down amendment was made to another public health bill, which contained language that basically said hospitalists and PCPs should talk to each other. This amendment asked that the Quality of Care Advisory Committee, which advises the Department of Public Health, make recommendations to the department concerning best practices with respect to communications between a patient’s PCP and other providers involved in a patient’s care, including hospitalists and specialists.

Thanks to CSMS’ and SHM’s efforts, no regulations or mandates are currently planned in Connecticut.

It is unfortunate that some states, driven by a small vocal group of consumers or sometimes by just one legislator, can single out hospitalists for scrutiny and regulation. Dr. Rifkin found out how important and necessary it is to provide education to the involved legislators, as some professed knowing few of the details of the hospital medicine movement.

While you might be sitting in Texas or Minnesota or California and wondering what all of this has to do with you, know that a wildfire can start from a smoldering ember. SHM must vigilantly monitor the actions of local legislatures and regulators so that in their misunderstanding of hospital medicine or in their concerns for changes in the healthcare system they do not attempt to use the state or federal legislatures for their remedies.

Hospital medicine is new, and we are challenging the status quo. While we are driven by a goal of creating a more efficient healthcare system, driven by accountability and data, some will see the turbulence of change and attempt to rein this in. While some places have seen significant improvements, hospital medicine is still very much in its growth and evolutionary phase. This is the time to have the ability for flexibility and even experimentation in the best sense of the word. It is important not to be stifled by overregulation. At the same time, hospitalists need to be aware that we are no longer a boutique specialty off on the margins of healthcare. Hospital medicine is front and center at more than 2,000 hospitals and with 15,000 hospitalists nationwide too large to be ignored.

Expect more attempts to legislate how hospitalists practice. One SHM member’s e-mail brought the full strength of SHM to quash the wrong bill in Connecticut. We need your local eyes to let us know what is happening out in the real world. In the meantime SHM will work hard to develop the bench strength to be able to rise to your challenges. TH

Dr. Wellikson has been CEO of SHM since 2000.

A few months ago SHM received an e-mail from SHM member Jennifer Bellino, MD, a hospitalist at William Backus Hospital in Norwich, Conn. She had gotten wind of a proposal flowing through the Public Health Committee at the Connecticut State Legislature that would mandate the frequency of communications between hospitalists and primary care physicians (PCPs). From her short e-mail SHM’s advocacy enterprise sprung into action.

Bill 5721 was being introduced to the Public Health Committee in the Connecticut Legislature, and it required the development of state regulations that would have governed the timing and frequency of communications between hospitalists and PCPs.

Laura Allendorf, SHM’s head of Governmental Affairs, engaged SHM’s Public Policy Committee to better understand the issues involved in this bill and to get a sense of whether this was a unique bill for Connecticut or whether it was being introduced in other state legislatures.

While the bill appeared to be isolated to Connecticut, the Public Policy Committee thought the issue was threatening enough to the practice of hospital medicine that local aggressive action was necessary.

Allendorf contacted the Connecticut State Medical Society and spoke to Ken Ferrucci, director of government relations, who was already aware of Bill 5721. The Connecticut State Medical Society (CSMS) was opposed to the bill as well, and Ferrucci proposed that SHM find a Connecticut hospitalist who could come to Hartford to speak against Bill 5721 at the Public Health Committee, which would hear testimony in just a few days.

Unfortunately, no one on the Public Policy Committee was from Connecticut. Fortunately, SHM was familiar with Bill Rifkin, MD, from Yale (New Haven) and Waterbury Hospital, who is active at SHM as a member of our Education Committee. Allendorf contacted Dr. Rifkin and explained the situation. He dropped everything on his calendar and changed his appointments and agreed to come to Hartford to fly the SHM banner and testify before the Public Health Committee.

Working together Allendorf, Eric Siegal, the Public Policy committee chair, and Dr. Rifkin crafted the testimony necessary to explain to the legislators just what hospital medicine is and what hospitalists do. In addition, they emphasized that hospitalists are working hard to be the experts in transitions of care and that mandates and regulations were not needed and, in fact, could be detrimental to the fundamental relationship between PCPs and hospitalists.

SHM then coordinated our approach with that of the Connecticut State Medical Society to create a unified front for maximum effectiveness. In the end Dr. Rifkin carried the day.

After Dr. Rifkin’s testimony, as well as testimony from the Connecticut State Medical Society, the bill died a quiet death. Eventually, a watered down amendment was made to another public health bill, which contained language that basically said hospitalists and PCPs should talk to each other. This amendment asked that the Quality of Care Advisory Committee, which advises the Department of Public Health, make recommendations to the department concerning best practices with respect to communications between a patient’s PCP and other providers involved in a patient’s care, including hospitalists and specialists.

Thanks to CSMS’ and SHM’s efforts, no regulations or mandates are currently planned in Connecticut.

It is unfortunate that some states, driven by a small vocal group of consumers or sometimes by just one legislator, can single out hospitalists for scrutiny and regulation. Dr. Rifkin found out how important and necessary it is to provide education to the involved legislators, as some professed knowing few of the details of the hospital medicine movement.

While you might be sitting in Texas or Minnesota or California and wondering what all of this has to do with you, know that a wildfire can start from a smoldering ember. SHM must vigilantly monitor the actions of local legislatures and regulators so that in their misunderstanding of hospital medicine or in their concerns for changes in the healthcare system they do not attempt to use the state or federal legislatures for their remedies.

Hospital medicine is new, and we are challenging the status quo. While we are driven by a goal of creating a more efficient healthcare system, driven by accountability and data, some will see the turbulence of change and attempt to rein this in. While some places have seen significant improvements, hospital medicine is still very much in its growth and evolutionary phase. This is the time to have the ability for flexibility and even experimentation in the best sense of the word. It is important not to be stifled by overregulation. At the same time, hospitalists need to be aware that we are no longer a boutique specialty off on the margins of healthcare. Hospital medicine is front and center at more than 2,000 hospitals and with 15,000 hospitalists nationwide too large to be ignored.

Expect more attempts to legislate how hospitalists practice. One SHM member’s e-mail brought the full strength of SHM to quash the wrong bill in Connecticut. We need your local eyes to let us know what is happening out in the real world. In the meantime SHM will work hard to develop the bench strength to be able to rise to your challenges. TH

Dr. Wellikson has been CEO of SHM since 2000.

A few months ago SHM received an e-mail from SHM member Jennifer Bellino, MD, a hospitalist at William Backus Hospital in Norwich, Conn. She had gotten wind of a proposal flowing through the Public Health Committee at the Connecticut State Legislature that would mandate the frequency of communications between hospitalists and primary care physicians (PCPs). From her short e-mail SHM’s advocacy enterprise sprung into action.

Bill 5721 was being introduced to the Public Health Committee in the Connecticut Legislature, and it required the development of state regulations that would have governed the timing and frequency of communications between hospitalists and PCPs.

Laura Allendorf, SHM’s head of Governmental Affairs, engaged SHM’s Public Policy Committee to better understand the issues involved in this bill and to get a sense of whether this was a unique bill for Connecticut or whether it was being introduced in other state legislatures.

While the bill appeared to be isolated to Connecticut, the Public Policy Committee thought the issue was threatening enough to the practice of hospital medicine that local aggressive action was necessary.

Allendorf contacted the Connecticut State Medical Society and spoke to Ken Ferrucci, director of government relations, who was already aware of Bill 5721. The Connecticut State Medical Society (CSMS) was opposed to the bill as well, and Ferrucci proposed that SHM find a Connecticut hospitalist who could come to Hartford to speak against Bill 5721 at the Public Health Committee, which would hear testimony in just a few days.

Unfortunately, no one on the Public Policy Committee was from Connecticut. Fortunately, SHM was familiar with Bill Rifkin, MD, from Yale (New Haven) and Waterbury Hospital, who is active at SHM as a member of our Education Committee. Allendorf contacted Dr. Rifkin and explained the situation. He dropped everything on his calendar and changed his appointments and agreed to come to Hartford to fly the SHM banner and testify before the Public Health Committee.

Working together Allendorf, Eric Siegal, the Public Policy committee chair, and Dr. Rifkin crafted the testimony necessary to explain to the legislators just what hospital medicine is and what hospitalists do. In addition, they emphasized that hospitalists are working hard to be the experts in transitions of care and that mandates and regulations were not needed and, in fact, could be detrimental to the fundamental relationship between PCPs and hospitalists.

SHM then coordinated our approach with that of the Connecticut State Medical Society to create a unified front for maximum effectiveness. In the end Dr. Rifkin carried the day.

After Dr. Rifkin’s testimony, as well as testimony from the Connecticut State Medical Society, the bill died a quiet death. Eventually, a watered down amendment was made to another public health bill, which contained language that basically said hospitalists and PCPs should talk to each other. This amendment asked that the Quality of Care Advisory Committee, which advises the Department of Public Health, make recommendations to the department concerning best practices with respect to communications between a patient’s PCP and other providers involved in a patient’s care, including hospitalists and specialists.

Thanks to CSMS’ and SHM’s efforts, no regulations or mandates are currently planned in Connecticut.

It is unfortunate that some states, driven by a small vocal group of consumers or sometimes by just one legislator, can single out hospitalists for scrutiny and regulation. Dr. Rifkin found out how important and necessary it is to provide education to the involved legislators, as some professed knowing few of the details of the hospital medicine movement.

While you might be sitting in Texas or Minnesota or California and wondering what all of this has to do with you, know that a wildfire can start from a smoldering ember. SHM must vigilantly monitor the actions of local legislatures and regulators so that in their misunderstanding of hospital medicine or in their concerns for changes in the healthcare system they do not attempt to use the state or federal legislatures for their remedies.

Hospital medicine is new, and we are challenging the status quo. While we are driven by a goal of creating a more efficient healthcare system, driven by accountability and data, some will see the turbulence of change and attempt to rein this in. While some places have seen significant improvements, hospital medicine is still very much in its growth and evolutionary phase. This is the time to have the ability for flexibility and even experimentation in the best sense of the word. It is important not to be stifled by overregulation. At the same time, hospitalists need to be aware that we are no longer a boutique specialty off on the margins of healthcare. Hospital medicine is front and center at more than 2,000 hospitals and with 15,000 hospitalists nationwide too large to be ignored.

Expect more attempts to legislate how hospitalists practice. One SHM member’s e-mail brought the full strength of SHM to quash the wrong bill in Connecticut. We need your local eyes to let us know what is happening out in the real world. In the meantime SHM will work hard to develop the bench strength to be able to rise to your challenges. TH

Dr. Wellikson has been CEO of SHM since 2000.

We are in the midst of a true evolution of how hospitals will approach creating a culture of quality. The drivers for process improvement and management of resources have traditionally been more concerned with full occupancy and risk management, but now many external forces are raising quality improvement as a potential core competency for our nation’s hospitals.

With the push of the Institute for Healthcare Improvement (IHI), Leapfrog, and even Medicare, hospitals now must grapple with a culture change—one in which measurement and reporting of outcomes and processes will become, if not truly job one, at least in the top five. The fact that a hospital’s revenue stream through pay-for-performance (P4P) bonuses and its reputation by public reporting are at stake only serve to create a real immediacy in the coming years.

A recent SHM survey of the leaders of hospital medicine groups (HMGs) has shown that, once again, hospitalists find themselves right smack in the middle of quality improvement.

Survey Says

More than 41% of hospitalist leaders report that their HMG has a quality incentive program. This is even more prevalent at hospitals participating in P4P programs, where 60% of HMGs have quality incentives to align priorities. It is a hallmark of hospitalist groups to place a particular emphasis on the process and system improvement necessary for true measurable quality improvement. Many times, this improvement takes time away from direct and billable patient care.

Pointing to the relatively early stage in the adoption of P4P, this same survey reported that only 29% of HMGs were working in hospitals that participated in P4P programs, while 56% report their hospital did not have any P4P programs in place.

As we enter 2007, it is clear that while a small percentage of hospitals have embraced P4P the majority of hospitals are—at best—on the sidelines or still in planning mode. But those who are active in P4P have engaged their hospitalists to help them meet their goals. And everything that is coming out in the literature commonly read by the hospital C-suite promotes the promise of more reimbursement from the insurance industry and Medicare, leading to the conclusion that P4P and rewarding performance will increase in the near term.

What Can SHM Do for You?

Positioning hospitalists to play a key role in quality improvement, SHM has launched a number of initiatives and partnerships to provide hospitalists with the tools they need to help their hospitals to succeed.

As a framework of tools, SHM has now built six Web-based Quality Improvement Resource Rooms in VTE, Heart Failure, Stroke, Glycemic Control, Care Transitions in the Elderly, and Antibiotic Resistance. These practical tools and references are now available on the SHM Web site (www.hospitalmedicine.org) as are, in many cases, a comprehensive workbook that helps hospitalists to be the leaders of quality improvement change at their hospitals.

SHM realizes that, while this approach may work for the savvy, experienced quality improvement (QI) implementer, most young hospitalist leaders need a more personal, hands-on approach. With this in mind, SHM has launched its Mentored QI Implementation project. Centered around VTE prevention and supported by funding from Sanofi-Aventis, two senior hospitalist mentors will each work with 15 HMG leaders to take them step by step through the process of implementing a quality improvement process in 2007 and 2008.

To take this hands-on, supportive approach to the next level SHM (with support from a Kettering Foundation grant) will add the capability for on-site consultation—sort of a QI SWAT team that can show up at your hospital and work shoulder to shoulder with hospitalists and other members of the healthcare team to develop and implement processes that will improve patient care.

To further educate and energize hospitalist leaders who have been charged with leading this change, SHM developed the Leadership Academy. To date more than 400 hospitalist leaders have been trained in sold-out small-group sessions during the past two years. The most recent academy was held last month in Orlando, Fla.

SHM provides additional training for those who will implement quality improvement at the Quality Training precourse at the SHM Annual Meeting. In the precourse up to 100 change leaders get hands-on direction, tools, and tricks of the trade to allow them to succeed in their local efforts. The next Quality Training Precourse will be held in small group sessions on May 23, 2007, in Dallas.

The SHM Annual Meeting has consistently been a venue that allows hospitalists to hear from national thought leaders in the quality revolution. In 2006, hospitalists heard from Carolyn Clancy, MD, CEO of the Agency for Healthcare Research and Quality, and Jack Rowe, MD, CEO of Aetna Insurance Company.

At this year’s meeting Jonathan Perlin, MD, PhD, who led the cutting edge QI efforts at Veterans Affairs and who is now bringing innovation to HCA (Nashville, Tenn.), the nation’s largest hospital company, will share his ideas with us. In addition, hospitalists will hear from David Brailer, MD, PhD, President George W. Bush’s first appointee to head up national efforts for health information technology. In addition, SHM’s Bob Wachter, MD, a nationally recognized leader in QI and patient safety, will share his perspectives on hospital medicine. With Drs. Perlin, Brailer, and Wachter, SHM continues its tradition of placing innovations that are changing healthcare for the better front and center at our annual meeting.

As for the future, SHM has submitted a multi-year grant application to the Hartford Foundation (Conn.) to expand our efforts—specifically in developing implementation strategies to improve the care processes and outcomes for the senior population.

One of the key areas that emerged from SHM’s work with the Hartford Foundation is the importance of improving the transitions of care and better coordinating healthcare from the patient’s point of view. This has led SHM to partner with several national organizations to make sense of what has been a squishy subject. SHM is working closely with the American Board of Internal Medicine (ABIM) Foundation on its Stepping Up to the Plate consortium, a group of specialty physicians focusing on best practice strategies in patient-centered transitions, hand-offs, and information transfer.

In addition, SHM is working with the American College of Physicians, the AHRQ, the ABIM, the American Geriatrics Society (AGS), and the Society of General Internal Medicine to hold a National Consensus Conference in 2007 to establish policy on transitions of care. The conference will involve a broad range of stakeholders and may very well lead to the establishment of performance standards that can be applied directly to patient care.

Also SHM has been working with the Case Management Society of America to bring together the broader healthcare team on its National Transitions of Care Coalition (NTOCC) project. NTOCC includes pharmacists (American Society of Health-System Pharmacists), the C-suite (American College of Healthcare Executives), social workers (National Association of Social Workers), geriatricians (the AGS), the Joint Commission on Accreditation of Healthcare Organizations, and others. NTOCC plans to develop clear tools, guidelines, and pathways for consistent communication among patients, providers, and payers throughout the care continuum, and to look at aligning incentives for use of these tools and resources.

SHM has also worked with recognized leaders in action-oriented campaigns in QI, including the IHI—first on its “100,000 Lives Campaign,” and more recently on its “5 Million Lives Campaign.” In fact, leadership from only one medical professional society—SHM—was on the stage with Don Berwick for IHI’s national announcement at the December 2006 IHI national meeting in Orlando.

Hospitalists Lead the Charge

It is clear that our nation’s hospitals will be incentivized and mandated to create processes and produce outcomes based on national performance standards and data. This will require a re-engineering of the hospitals and their medical staffs. Hospitalists will be charged (as part of their job description) to be physician leaders in making this happen. Unfortunately, their training in medical school or residency has not provided them with all the skills in QI measurement or implementation that they will need. That is where SHM comes in.

Whether developing tools and workbooks or developing educational and implementation strategies, SHM will be innovative and on the cutting edge. Just as importantly, SHM will be on the lookout for like-minded organizations to partner with to raise the visibility and necessity of QI. We will not shy away from helping to set performance standards just because they may create initial discomfort with some of our members. We will not back off from developing creative strategies to push QI down to more than 4,000 acute care hospitals just because it is difficult and at times daunting.

Hospitalists are on the front line of change. Our patients, our institutions, our fellow physicians, and the other members of the healthcare team want and need a better system. There is no standing still. There is no turning back. The time is now. It is our turn, and hospitalists, with SHM’s help, are ready to step up and make it happen. TH

Dr. Wellikson has been CEO of SHM since 2000.

We are in the midst of a true evolution of how hospitals will approach creating a culture of quality. The drivers for process improvement and management of resources have traditionally been more concerned with full occupancy and risk management, but now many external forces are raising quality improvement as a potential core competency for our nation’s hospitals.

With the push of the Institute for Healthcare Improvement (IHI), Leapfrog, and even Medicare, hospitals now must grapple with a culture change—one in which measurement and reporting of outcomes and processes will become, if not truly job one, at least in the top five. The fact that a hospital’s revenue stream through pay-for-performance (P4P) bonuses and its reputation by public reporting are at stake only serve to create a real immediacy in the coming years.

A recent SHM survey of the leaders of hospital medicine groups (HMGs) has shown that, once again, hospitalists find themselves right smack in the middle of quality improvement.

Survey Says

More than 41% of hospitalist leaders report that their HMG has a quality incentive program. This is even more prevalent at hospitals participating in P4P programs, where 60% of HMGs have quality incentives to align priorities. It is a hallmark of hospitalist groups to place a particular emphasis on the process and system improvement necessary for true measurable quality improvement. Many times, this improvement takes time away from direct and billable patient care.

Pointing to the relatively early stage in the adoption of P4P, this same survey reported that only 29% of HMGs were working in hospitals that participated in P4P programs, while 56% report their hospital did not have any P4P programs in place.

As we enter 2007, it is clear that while a small percentage of hospitals have embraced P4P the majority of hospitals are—at best—on the sidelines or still in planning mode. But those who are active in P4P have engaged their hospitalists to help them meet their goals. And everything that is coming out in the literature commonly read by the hospital C-suite promotes the promise of more reimbursement from the insurance industry and Medicare, leading to the conclusion that P4P and rewarding performance will increase in the near term.

What Can SHM Do for You?

Positioning hospitalists to play a key role in quality improvement, SHM has launched a number of initiatives and partnerships to provide hospitalists with the tools they need to help their hospitals to succeed.

As a framework of tools, SHM has now built six Web-based Quality Improvement Resource Rooms in VTE, Heart Failure, Stroke, Glycemic Control, Care Transitions in the Elderly, and Antibiotic Resistance. These practical tools and references are now available on the SHM Web site (www.hospitalmedicine.org) as are, in many cases, a comprehensive workbook that helps hospitalists to be the leaders of quality improvement change at their hospitals.

SHM realizes that, while this approach may work for the savvy, experienced quality improvement (QI) implementer, most young hospitalist leaders need a more personal, hands-on approach. With this in mind, SHM has launched its Mentored QI Implementation project. Centered around VTE prevention and supported by funding from Sanofi-Aventis, two senior hospitalist mentors will each work with 15 HMG leaders to take them step by step through the process of implementing a quality improvement process in 2007 and 2008.

To take this hands-on, supportive approach to the next level SHM (with support from a Kettering Foundation grant) will add the capability for on-site consultation—sort of a QI SWAT team that can show up at your hospital and work shoulder to shoulder with hospitalists and other members of the healthcare team to develop and implement processes that will improve patient care.

To further educate and energize hospitalist leaders who have been charged with leading this change, SHM developed the Leadership Academy. To date more than 400 hospitalist leaders have been trained in sold-out small-group sessions during the past two years. The most recent academy was held last month in Orlando, Fla.

SHM provides additional training for those who will implement quality improvement at the Quality Training precourse at the SHM Annual Meeting. In the precourse up to 100 change leaders get hands-on direction, tools, and tricks of the trade to allow them to succeed in their local efforts. The next Quality Training Precourse will be held in small group sessions on May 23, 2007, in Dallas.

The SHM Annual Meeting has consistently been a venue that allows hospitalists to hear from national thought leaders in the quality revolution. In 2006, hospitalists heard from Carolyn Clancy, MD, CEO of the Agency for Healthcare Research and Quality, and Jack Rowe, MD, CEO of Aetna Insurance Company.

At this year’s meeting Jonathan Perlin, MD, PhD, who led the cutting edge QI efforts at Veterans Affairs and who is now bringing innovation to HCA (Nashville, Tenn.), the nation’s largest hospital company, will share his ideas with us. In addition, hospitalists will hear from David Brailer, MD, PhD, President George W. Bush’s first appointee to head up national efforts for health information technology. In addition, SHM’s Bob Wachter, MD, a nationally recognized leader in QI and patient safety, will share his perspectives on hospital medicine. With Drs. Perlin, Brailer, and Wachter, SHM continues its tradition of placing innovations that are changing healthcare for the better front and center at our annual meeting.

As for the future, SHM has submitted a multi-year grant application to the Hartford Foundation (Conn.) to expand our efforts—specifically in developing implementation strategies to improve the care processes and outcomes for the senior population.

One of the key areas that emerged from SHM’s work with the Hartford Foundation is the importance of improving the transitions of care and better coordinating healthcare from the patient’s point of view. This has led SHM to partner with several national organizations to make sense of what has been a squishy subject. SHM is working closely with the American Board of Internal Medicine (ABIM) Foundation on its Stepping Up to the Plate consortium, a group of specialty physicians focusing on best practice strategies in patient-centered transitions, hand-offs, and information transfer.

In addition, SHM is working with the American College of Physicians, the AHRQ, the ABIM, the American Geriatrics Society (AGS), and the Society of General Internal Medicine to hold a National Consensus Conference in 2007 to establish policy on transitions of care. The conference will involve a broad range of stakeholders and may very well lead to the establishment of performance standards that can be applied directly to patient care.

Also SHM has been working with the Case Management Society of America to bring together the broader healthcare team on its National Transitions of Care Coalition (NTOCC) project. NTOCC includes pharmacists (American Society of Health-System Pharmacists), the C-suite (American College of Healthcare Executives), social workers (National Association of Social Workers), geriatricians (the AGS), the Joint Commission on Accreditation of Healthcare Organizations, and others. NTOCC plans to develop clear tools, guidelines, and pathways for consistent communication among patients, providers, and payers throughout the care continuum, and to look at aligning incentives for use of these tools and resources.

SHM has also worked with recognized leaders in action-oriented campaigns in QI, including the IHI—first on its “100,000 Lives Campaign,” and more recently on its “5 Million Lives Campaign.” In fact, leadership from only one medical professional society—SHM—was on the stage with Don Berwick for IHI’s national announcement at the December 2006 IHI national meeting in Orlando.

Hospitalists Lead the Charge

It is clear that our nation’s hospitals will be incentivized and mandated to create processes and produce outcomes based on national performance standards and data. This will require a re-engineering of the hospitals and their medical staffs. Hospitalists will be charged (as part of their job description) to be physician leaders in making this happen. Unfortunately, their training in medical school or residency has not provided them with all the skills in QI measurement or implementation that they will need. That is where SHM comes in.

Whether developing tools and workbooks or developing educational and implementation strategies, SHM will be innovative and on the cutting edge. Just as importantly, SHM will be on the lookout for like-minded organizations to partner with to raise the visibility and necessity of QI. We will not shy away from helping to set performance standards just because they may create initial discomfort with some of our members. We will not back off from developing creative strategies to push QI down to more than 4,000 acute care hospitals just because it is difficult and at times daunting.

Hospitalists are on the front line of change. Our patients, our institutions, our fellow physicians, and the other members of the healthcare team want and need a better system. There is no standing still. There is no turning back. The time is now. It is our turn, and hospitalists, with SHM’s help, are ready to step up and make it happen. TH

Dr. Wellikson has been CEO of SHM since 2000.

We are in the midst of a true evolution of how hospitals will approach creating a culture of quality. The drivers for process improvement and management of resources have traditionally been more concerned with full occupancy and risk management, but now many external forces are raising quality improvement as a potential core competency for our nation’s hospitals.

With the push of the Institute for Healthcare Improvement (IHI), Leapfrog, and even Medicare, hospitals now must grapple with a culture change—one in which measurement and reporting of outcomes and processes will become, if not truly job one, at least in the top five. The fact that a hospital’s revenue stream through pay-for-performance (P4P) bonuses and its reputation by public reporting are at stake only serve to create a real immediacy in the coming years.

A recent SHM survey of the leaders of hospital medicine groups (HMGs) has shown that, once again, hospitalists find themselves right smack in the middle of quality improvement.

Survey Says

More than 41% of hospitalist leaders report that their HMG has a quality incentive program. This is even more prevalent at hospitals participating in P4P programs, where 60% of HMGs have quality incentives to align priorities. It is a hallmark of hospitalist groups to place a particular emphasis on the process and system improvement necessary for true measurable quality improvement. Many times, this improvement takes time away from direct and billable patient care.

Pointing to the relatively early stage in the adoption of P4P, this same survey reported that only 29% of HMGs were working in hospitals that participated in P4P programs, while 56% report their hospital did not have any P4P programs in place.

As we enter 2007, it is clear that while a small percentage of hospitals have embraced P4P the majority of hospitals are—at best—on the sidelines or still in planning mode. But those who are active in P4P have engaged their hospitalists to help them meet their goals. And everything that is coming out in the literature commonly read by the hospital C-suite promotes the promise of more reimbursement from the insurance industry and Medicare, leading to the conclusion that P4P and rewarding performance will increase in the near term.

What Can SHM Do for You?

Positioning hospitalists to play a key role in quality improvement, SHM has launched a number of initiatives and partnerships to provide hospitalists with the tools they need to help their hospitals to succeed.

As a framework of tools, SHM has now built six Web-based Quality Improvement Resource Rooms in VTE, Heart Failure, Stroke, Glycemic Control, Care Transitions in the Elderly, and Antibiotic Resistance. These practical tools and references are now available on the SHM Web site (www.hospitalmedicine.org) as are, in many cases, a comprehensive workbook that helps hospitalists to be the leaders of quality improvement change at their hospitals.

SHM realizes that, while this approach may work for the savvy, experienced quality improvement (QI) implementer, most young hospitalist leaders need a more personal, hands-on approach. With this in mind, SHM has launched its Mentored QI Implementation project. Centered around VTE prevention and supported by funding from Sanofi-Aventis, two senior hospitalist mentors will each work with 15 HMG leaders to take them step by step through the process of implementing a quality improvement process in 2007 and 2008.

To take this hands-on, supportive approach to the next level SHM (with support from a Kettering Foundation grant) will add the capability for on-site consultation—sort of a QI SWAT team that can show up at your hospital and work shoulder to shoulder with hospitalists and other members of the healthcare team to develop and implement processes that will improve patient care.

To further educate and energize hospitalist leaders who have been charged with leading this change, SHM developed the Leadership Academy. To date more than 400 hospitalist leaders have been trained in sold-out small-group sessions during the past two years. The most recent academy was held last month in Orlando, Fla.

SHM provides additional training for those who will implement quality improvement at the Quality Training precourse at the SHM Annual Meeting. In the precourse up to 100 change leaders get hands-on direction, tools, and tricks of the trade to allow them to succeed in their local efforts. The next Quality Training Precourse will be held in small group sessions on May 23, 2007, in Dallas.

The SHM Annual Meeting has consistently been a venue that allows hospitalists to hear from national thought leaders in the quality revolution. In 2006, hospitalists heard from Carolyn Clancy, MD, CEO of the Agency for Healthcare Research and Quality, and Jack Rowe, MD, CEO of Aetna Insurance Company.

At this year’s meeting Jonathan Perlin, MD, PhD, who led the cutting edge QI efforts at Veterans Affairs and who is now bringing innovation to HCA (Nashville, Tenn.), the nation’s largest hospital company, will share his ideas with us. In addition, hospitalists will hear from David Brailer, MD, PhD, President George W. Bush’s first appointee to head up national efforts for health information technology. In addition, SHM’s Bob Wachter, MD, a nationally recognized leader in QI and patient safety, will share his perspectives on hospital medicine. With Drs. Perlin, Brailer, and Wachter, SHM continues its tradition of placing innovations that are changing healthcare for the better front and center at our annual meeting.

As for the future, SHM has submitted a multi-year grant application to the Hartford Foundation (Conn.) to expand our efforts—specifically in developing implementation strategies to improve the care processes and outcomes for the senior population.

One of the key areas that emerged from SHM’s work with the Hartford Foundation is the importance of improving the transitions of care and better coordinating healthcare from the patient’s point of view. This has led SHM to partner with several national organizations to make sense of what has been a squishy subject. SHM is working closely with the American Board of Internal Medicine (ABIM) Foundation on its Stepping Up to the Plate consortium, a group of specialty physicians focusing on best practice strategies in patient-centered transitions, hand-offs, and information transfer.

In addition, SHM is working with the American College of Physicians, the AHRQ, the ABIM, the American Geriatrics Society (AGS), and the Society of General Internal Medicine to hold a National Consensus Conference in 2007 to establish policy on transitions of care. The conference will involve a broad range of stakeholders and may very well lead to the establishment of performance standards that can be applied directly to patient care.

Also SHM has been working with the Case Management Society of America to bring together the broader healthcare team on its National Transitions of Care Coalition (NTOCC) project. NTOCC includes pharmacists (American Society of Health-System Pharmacists), the C-suite (American College of Healthcare Executives), social workers (National Association of Social Workers), geriatricians (the AGS), the Joint Commission on Accreditation of Healthcare Organizations, and others. NTOCC plans to develop clear tools, guidelines, and pathways for consistent communication among patients, providers, and payers throughout the care continuum, and to look at aligning incentives for use of these tools and resources.

SHM has also worked with recognized leaders in action-oriented campaigns in QI, including the IHI—first on its “100,000 Lives Campaign,” and more recently on its “5 Million Lives Campaign.” In fact, leadership from only one medical professional society—SHM—was on the stage with Don Berwick for IHI’s national announcement at the December 2006 IHI national meeting in Orlando.

Hospitalists Lead the Charge

It is clear that our nation’s hospitals will be incentivized and mandated to create processes and produce outcomes based on national performance standards and data. This will require a re-engineering of the hospitals and their medical staffs. Hospitalists will be charged (as part of their job description) to be physician leaders in making this happen. Unfortunately, their training in medical school or residency has not provided them with all the skills in QI measurement or implementation that they will need. That is where SHM comes in.

Whether developing tools and workbooks or developing educational and implementation strategies, SHM will be innovative and on the cutting edge. Just as importantly, SHM will be on the lookout for like-minded organizations to partner with to raise the visibility and necessity of QI. We will not shy away from helping to set performance standards just because they may create initial discomfort with some of our members. We will not back off from developing creative strategies to push QI down to more than 4,000 acute care hospitals just because it is difficult and at times daunting.

Hospitalists are on the front line of change. Our patients, our institutions, our fellow physicians, and the other members of the healthcare team want and need a better system. There is no standing still. There is no turning back. The time is now. It is our turn, and hospitalists, with SHM’s help, are ready to step up and make it happen. TH

Dr. Wellikson has been CEO of SHM since 2000.

In an historic decision at its October 2006 board meeting, the American Board of Internal Medicine (ABIM) agreed to move forward to develop a process for Focused Recognition of Hospital Medicine through ABIM’s Maintenance of Certification (MOC). This is the first time ABIM has offered focused recognition for any subset of internal medicine. In addition, this brings recognition to the uniqueness of hospitalists, who dedicate their professional careers to managing the care of acutely ill patients and creating a better healthcare delivery process at their local hospitals.

This whole concept started when the SHM Board approved a resolution in February 2004, outlining the need to recognize hospitalists as unique providers of healthcare. At the time, the SHM Board asked SHM staff and leadership to work with existing certifying organizations, such as ABIM, to develop a mechanism for hospitalists to have a formal credential recognizing hospital medicine.

Because more than 80% of hospitalists are initially trained in internal medicine, SHM leadership decided that it made sense to first approach ABIM. At the same time SHM had plans to develop similar solutions for hospitalists who are trained initially as pediatricians, family practitioners, and osteopaths (all of which are certified by boards other than ABIM).

Soon after the 2004 SHM Board meeting, SHM executive staff approached key leaders at ABIM. ABIM held a retreat in 2004 to discuss new models of certification. Later the ABIM Board encouraged meetings with SHM to keep hospital medicine within internal medicine.

In April 2005 ABIM and SHM leadership agreed that recognition of hospitalists initially trained in internal medicine might be achieved by modifying the existing MOC process. At that time the ABIM Board was concerned that any changes to the certification system might fragment the internal medicine community. To its credit the ABIM Board did not let these concerns block the process. ABIM soon convened a range of stakeholders in internal medicine to address these issues.

This group of stakeholders was broadly drawn from the leadership at SHM, the American College of Physicians, the Society of General Internal Medicine, all medical subspecialties, the Alliance for Academic Internal Medicine, the Association of American Medical Colleges, the AMA, the Residency Review Committee, and ABIM itself. These stakeholders met in December 2005, May 2006, and again in September 2006.

In preparation for these meetings SHM had developed its comprehensive Core Competencies in Hospital Medicine that was published as a supplement to the first issue of the Journal of Hospital Medicine (JHM) in February 2006. This was a powerful, tangible set of circumstances for hospital medicine.

When people began questioning what made hospital medicine unique among internal medicine disciplines or what was the substance of hospital medicine, being able to hand them the Core Competencies and to walk them through this thoughtful document was very important. In the same way, establishing our own repository for medical advances in hospital medicine via JHM also supported the development of a new field in internal medicine.

It’s been helpful that other key trends have taken shape in the last few years. The Alliance for Academic Internal Medicine (AAIM), representing the Association of Professors of Medicine (APM) and the Association of Directors of Programs in Internal Medicine (APDIM) and others, worked closely with ACP and the rest of the specialties in internal medicine to redesign the internal medicine residency so that it reflects the current and future practice environment.

Further, throughout healthcare there has been an increasing call for performance standards and quality improvement—all in the context of using resources more efficiently. There has been a movement to reshape healthcare centered on the patient and delivered by teams of health professionals, as well as increasing calls to coordinate care across locales and providers so as to improve patient safety and provide the best care.

In addition, the growth of hospital medicine has accelerated in the last few years. The fact that data not only from SHM but also from the American Hospital Association (AHA) and others show that more than 15,000 hospitalists now practice at more than 2,000 hospitals illustrates that that the size and influence of hospitalists comprise an indisputable trend.

And for many hospitals the driver for developing hospital medicine groups is the need to have on-site health professionals who are committed to changes in quality, systems improvement, patient safety, and efficiency.

Whether you call this a tipping point à la Malcolm Gladwell (The Tipping Point, New York City: Little, Brown and Company; 2000) or a perfect storm, to its credit ABIM—with the support of ACP, AAIM, and others—saw an opportunity to develop meaningful changes to MOC as a means of identifying hospitalists and of motivating the self study and improvement in skills and knowledge so important to meet the demands of healthcare delivery in the 21st century.

Now the hard work begins. In October 2006 the ABIM Board of Directors approved appointment of an ABIM Committee on Hospital Medicine Focused Recognition (HMFR). This work group will make recommendations to the ABIM Board in 2007 regarding the requirements for evidence of proficiency in HMFR in the MOC process as well as recommending policy of how HMFR would relate to the rest of ABIM certification and MOC in internal medicine.

SHM and hospital medicine leaders intend to play a key role in helping ABIM shape the details of the HMFR process so that it’s meaningful to the hospitalists who choose to get HMFR during their MOC—as well as to those who employ hospitalists, the physicians and other health professionals that hospitalists work with, the hospitals we work in, and the patients we care for.

At the same time ABIM must approach the American Board of Medical Specialties (ABMS) because the ABMS will ultimately need to accept the HMFR process before ABIM can put this new process in place. This is a significant hurdle to clear, but the ABIM Board is committed to using its resources and powers of persuasion to make this happen.

Even with the hard work and political battles ahead, it is difficult not to sit back and marvel at how far we have come. Our specialty is just 10 years old, but we now have more than 15,000 practitioners and are on our way to 30,000 or even 40,000. We have our own journal, our own specialty society, our own set of competencies, our own growing national annual meeting, our own textbooks, and a growing number of publications aimed at hospitalists.

Now with the help of ABIM and the blessing of ABMS, there is a serious prospect that the first recognition of hospital medicine in the certification process will become a reality.

Will the first hospitalist claim Hospital Medicine Focused Recognition in 2008 or 2009? The exact date is too difficult to predict. That it will happen and that it will be meaningful is more certain now than it has ever been. To all those who have had the foresight and leadership to make this a reality, we thank you. Now let’s get down to the difficult work of creating a process that will help hospitalists provide the best care to their patients and help them to be leaders of change and improvement at their institutions. TH

Dr. Wellikson has been CEO of SHM since 2000.

In an historic decision at its October 2006 board meeting, the American Board of Internal Medicine (ABIM) agreed to move forward to develop a process for Focused Recognition of Hospital Medicine through ABIM’s Maintenance of Certification (MOC). This is the first time ABIM has offered focused recognition for any subset of internal medicine. In addition, this brings recognition to the uniqueness of hospitalists, who dedicate their professional careers to managing the care of acutely ill patients and creating a better healthcare delivery process at their local hospitals.

This whole concept started when the SHM Board approved a resolution in February 2004, outlining the need to recognize hospitalists as unique providers of healthcare. At the time, the SHM Board asked SHM staff and leadership to work with existing certifying organizations, such as ABIM, to develop a mechanism for hospitalists to have a formal credential recognizing hospital medicine.

Because more than 80% of hospitalists are initially trained in internal medicine, SHM leadership decided that it made sense to first approach ABIM. At the same time SHM had plans to develop similar solutions for hospitalists who are trained initially as pediatricians, family practitioners, and osteopaths (all of which are certified by boards other than ABIM).

Soon after the 2004 SHM Board meeting, SHM executive staff approached key leaders at ABIM. ABIM held a retreat in 2004 to discuss new models of certification. Later the ABIM Board encouraged meetings with SHM to keep hospital medicine within internal medicine.

In April 2005 ABIM and SHM leadership agreed that recognition of hospitalists initially trained in internal medicine might be achieved by modifying the existing MOC process. At that time the ABIM Board was concerned that any changes to the certification system might fragment the internal medicine community. To its credit the ABIM Board did not let these concerns block the process. ABIM soon convened a range of stakeholders in internal medicine to address these issues.

This group of stakeholders was broadly drawn from the leadership at SHM, the American College of Physicians, the Society of General Internal Medicine, all medical subspecialties, the Alliance for Academic Internal Medicine, the Association of American Medical Colleges, the AMA, the Residency Review Committee, and ABIM itself. These stakeholders met in December 2005, May 2006, and again in September 2006.

In preparation for these meetings SHM had developed its comprehensive Core Competencies in Hospital Medicine that was published as a supplement to the first issue of the Journal of Hospital Medicine (JHM) in February 2006. This was a powerful, tangible set of circumstances for hospital medicine.

When people began questioning what made hospital medicine unique among internal medicine disciplines or what was the substance of hospital medicine, being able to hand them the Core Competencies and to walk them through this thoughtful document was very important. In the same way, establishing our own repository for medical advances in hospital medicine via JHM also supported the development of a new field in internal medicine.

It’s been helpful that other key trends have taken shape in the last few years. The Alliance for Academic Internal Medicine (AAIM), representing the Association of Professors of Medicine (APM) and the Association of Directors of Programs in Internal Medicine (APDIM) and others, worked closely with ACP and the rest of the specialties in internal medicine to redesign the internal medicine residency so that it reflects the current and future practice environment.

Further, throughout healthcare there has been an increasing call for performance standards and quality improvement—all in the context of using resources more efficiently. There has been a movement to reshape healthcare centered on the patient and delivered by teams of health professionals, as well as increasing calls to coordinate care across locales and providers so as to improve patient safety and provide the best care.

In addition, the growth of hospital medicine has accelerated in the last few years. The fact that data not only from SHM but also from the American Hospital Association (AHA) and others show that more than 15,000 hospitalists now practice at more than 2,000 hospitals illustrates that that the size and influence of hospitalists comprise an indisputable trend.

And for many hospitals the driver for developing hospital medicine groups is the need to have on-site health professionals who are committed to changes in quality, systems improvement, patient safety, and efficiency.

Whether you call this a tipping point à la Malcolm Gladwell (The Tipping Point, New York City: Little, Brown and Company; 2000) or a perfect storm, to its credit ABIM—with the support of ACP, AAIM, and others—saw an opportunity to develop meaningful changes to MOC as a means of identifying hospitalists and of motivating the self study and improvement in skills and knowledge so important to meet the demands of healthcare delivery in the 21st century.

Now the hard work begins. In October 2006 the ABIM Board of Directors approved appointment of an ABIM Committee on Hospital Medicine Focused Recognition (HMFR). This work group will make recommendations to the ABIM Board in 2007 regarding the requirements for evidence of proficiency in HMFR in the MOC process as well as recommending policy of how HMFR would relate to the rest of ABIM certification and MOC in internal medicine.

SHM and hospital medicine leaders intend to play a key role in helping ABIM shape the details of the HMFR process so that it’s meaningful to the hospitalists who choose to get HMFR during their MOC—as well as to those who employ hospitalists, the physicians and other health professionals that hospitalists work with, the hospitals we work in, and the patients we care for.

At the same time ABIM must approach the American Board of Medical Specialties (ABMS) because the ABMS will ultimately need to accept the HMFR process before ABIM can put this new process in place. This is a significant hurdle to clear, but the ABIM Board is committed to using its resources and powers of persuasion to make this happen.

Even with the hard work and political battles ahead, it is difficult not to sit back and marvel at how far we have come. Our specialty is just 10 years old, but we now have more than 15,000 practitioners and are on our way to 30,000 or even 40,000. We have our own journal, our own specialty society, our own set of competencies, our own growing national annual meeting, our own textbooks, and a growing number of publications aimed at hospitalists.

Now with the help of ABIM and the blessing of ABMS, there is a serious prospect that the first recognition of hospital medicine in the certification process will become a reality.

Will the first hospitalist claim Hospital Medicine Focused Recognition in 2008 or 2009? The exact date is too difficult to predict. That it will happen and that it will be meaningful is more certain now than it has ever been. To all those who have had the foresight and leadership to make this a reality, we thank you. Now let’s get down to the difficult work of creating a process that will help hospitalists provide the best care to their patients and help them to be leaders of change and improvement at their institutions. TH

Dr. Wellikson has been CEO of SHM since 2000.

In an historic decision at its October 2006 board meeting, the American Board of Internal Medicine (ABIM) agreed to move forward to develop a process for Focused Recognition of Hospital Medicine through ABIM’s Maintenance of Certification (MOC). This is the first time ABIM has offered focused recognition for any subset of internal medicine. In addition, this brings recognition to the uniqueness of hospitalists, who dedicate their professional careers to managing the care of acutely ill patients and creating a better healthcare delivery process at their local hospitals.

This whole concept started when the SHM Board approved a resolution in February 2004, outlining the need to recognize hospitalists as unique providers of healthcare. At the time, the SHM Board asked SHM staff and leadership to work with existing certifying organizations, such as ABIM, to develop a mechanism for hospitalists to have a formal credential recognizing hospital medicine.

Because more than 80% of hospitalists are initially trained in internal medicine, SHM leadership decided that it made sense to first approach ABIM. At the same time SHM had plans to develop similar solutions for hospitalists who are trained initially as pediatricians, family practitioners, and osteopaths (all of which are certified by boards other than ABIM).

Soon after the 2004 SHM Board meeting, SHM executive staff approached key leaders at ABIM. ABIM held a retreat in 2004 to discuss new models of certification. Later the ABIM Board encouraged meetings with SHM to keep hospital medicine within internal medicine.

In April 2005 ABIM and SHM leadership agreed that recognition of hospitalists initially trained in internal medicine might be achieved by modifying the existing MOC process. At that time the ABIM Board was concerned that any changes to the certification system might fragment the internal medicine community. To its credit the ABIM Board did not let these concerns block the process. ABIM soon convened a range of stakeholders in internal medicine to address these issues.

This group of stakeholders was broadly drawn from the leadership at SHM, the American College of Physicians, the Society of General Internal Medicine, all medical subspecialties, the Alliance for Academic Internal Medicine, the Association of American Medical Colleges, the AMA, the Residency Review Committee, and ABIM itself. These stakeholders met in December 2005, May 2006, and again in September 2006.

In preparation for these meetings SHM had developed its comprehensive Core Competencies in Hospital Medicine that was published as a supplement to the first issue of the Journal of Hospital Medicine (JHM) in February 2006. This was a powerful, tangible set of circumstances for hospital medicine.

When people began questioning what made hospital medicine unique among internal medicine disciplines or what was the substance of hospital medicine, being able to hand them the Core Competencies and to walk them through this thoughtful document was very important. In the same way, establishing our own repository for medical advances in hospital medicine via JHM also supported the development of a new field in internal medicine.

It’s been helpful that other key trends have taken shape in the last few years. The Alliance for Academic Internal Medicine (AAIM), representing the Association of Professors of Medicine (APM) and the Association of Directors of Programs in Internal Medicine (APDIM) and others, worked closely with ACP and the rest of the specialties in internal medicine to redesign the internal medicine residency so that it reflects the current and future practice environment.

Further, throughout healthcare there has been an increasing call for performance standards and quality improvement—all in the context of using resources more efficiently. There has been a movement to reshape healthcare centered on the patient and delivered by teams of health professionals, as well as increasing calls to coordinate care across locales and providers so as to improve patient safety and provide the best care.

In addition, the growth of hospital medicine has accelerated in the last few years. The fact that data not only from SHM but also from the American Hospital Association (AHA) and others show that more than 15,000 hospitalists now practice at more than 2,000 hospitals illustrates that that the size and influence of hospitalists comprise an indisputable trend.

And for many hospitals the driver for developing hospital medicine groups is the need to have on-site health professionals who are committed to changes in quality, systems improvement, patient safety, and efficiency.

Whether you call this a tipping point à la Malcolm Gladwell (The Tipping Point, New York City: Little, Brown and Company; 2000) or a perfect storm, to its credit ABIM—with the support of ACP, AAIM, and others—saw an opportunity to develop meaningful changes to MOC as a means of identifying hospitalists and of motivating the self study and improvement in skills and knowledge so important to meet the demands of healthcare delivery in the 21st century.

Now the hard work begins. In October 2006 the ABIM Board of Directors approved appointment of an ABIM Committee on Hospital Medicine Focused Recognition (HMFR). This work group will make recommendations to the ABIM Board in 2007 regarding the requirements for evidence of proficiency in HMFR in the MOC process as well as recommending policy of how HMFR would relate to the rest of ABIM certification and MOC in internal medicine.

SHM and hospital medicine leaders intend to play a key role in helping ABIM shape the details of the HMFR process so that it’s meaningful to the hospitalists who choose to get HMFR during their MOC—as well as to those who employ hospitalists, the physicians and other health professionals that hospitalists work with, the hospitals we work in, and the patients we care for.

At the same time ABIM must approach the American Board of Medical Specialties (ABMS) because the ABMS will ultimately need to accept the HMFR process before ABIM can put this new process in place. This is a significant hurdle to clear, but the ABIM Board is committed to using its resources and powers of persuasion to make this happen.

Even with the hard work and political battles ahead, it is difficult not to sit back and marvel at how far we have come. Our specialty is just 10 years old, but we now have more than 15,000 practitioners and are on our way to 30,000 or even 40,000. We have our own journal, our own specialty society, our own set of competencies, our own growing national annual meeting, our own textbooks, and a growing number of publications aimed at hospitalists.

Now with the help of ABIM and the blessing of ABMS, there is a serious prospect that the first recognition of hospital medicine in the certification process will become a reality.

Will the first hospitalist claim Hospital Medicine Focused Recognition in 2008 or 2009? The exact date is too difficult to predict. That it will happen and that it will be meaningful is more certain now than it has ever been. To all those who have had the foresight and leadership to make this a reality, we thank you. Now let’s get down to the difficult work of creating a process that will help hospitalists provide the best care to their patients and help them to be leaders of change and improvement at their institutions. TH

Dr. Wellikson has been CEO of SHM since 2000.

The byproduct of tighter bottom lines for America’s industry is the big squeeze in health benefits. Those still lucky enough to have employer-based insurance coverage most likely have higher deductibles and co-pays or have been shifted to plans with a limited choice of providers. For those 1.3 million who have become uninsured in the past year, welcome to the growing legions of working class Americans who are “going bare” and hoping for good health.

As the chart below indicates, data just released from the government shows the steady and relentless rise in our country’s uninsured population.

This past year we have added 1.3 million new Americans to this very vulnerable group. And many of these people work full time.

Rethinking Your Stereotype of the Uninsured

Let me help you discard your stereotypes regarding the uninsured. Many are the working poor. They are caught in that dangerous economic wasteland between poverty and unemployment with the benefits of Medicaid and the ability to purchase affordable health insurance that will leave them with enough left over to feed, clothe, and house their families.

There are 37.8 million Americans of working age without insurance, and 27.3 million of them actually had paying jobs for some or all of last year. Even more astounding, the number of uninsured full-time workers grew by 1 million, from 20.5 million in 2004 to 21.5 million in 2005. Only 27.3% of uninsured Americans did not work at all.

This is not solely a problem for the poor and uneducated. More than 5 million of the uninsured had a college degree, more than 15 million had attended college at one time, and 22.6% had household incomes of more than $50,000 a year.

This is a particular problem for young Americans. Almost 70% of the uninsured are under 35 years of age. Even more disturbing, the number of children without insurance coverage rose from 7.9 million in 2004 to 8.3 million in 2005. This phenomenon occurred despite a number of legislative efforts to cover children and the allocation of extra resources in many states for sign-up drives organized to enroll more children.

The racial makeup of the uninsured population may surprise you as well. More than 22 million uninsured are non-Hispanic whites. In an emergent trend, however, an increasing percentage of the uninsured are Hispanic. There are now more than 14 million uninsured Hispanics in this country, representing a growing percentage of the Hispanic population in states such as California and Texas.

Implications for Hospitals and Hospitalists

Like emergency department physicians, hospitalists are hospital-based and ready to take all comers—regardless of insurance coverage or ability to pay the bills. On the clinical side, it is well known that those without insurance coverage generally avoid outpatient services that might have prevented an acute hospitalization. In addition, there is more often a chance for a falloff in post-discharge medical follow-up in those who lack insurance and a supportive outpatient physician. This can lead to unnecessary morbidity and readmissions.

For hospitals, finding a specialist to manage the patients in the emergency department or to co-manage with the hospitalist upon admission creates an additional strain. Depending on the hospital’s locale and patient mix, any increase in patients who are “self pay,” or uninsured, creates a financial strain that can affect the hospitalist service, as well as other hospital-supported clinical functions.

Implications for Patients

Some people with no insurance coverage just won’t get healthcare until they are in extremis—a costly choice for the patient’s well being and longevity, as well as for the entire health system.

More recently, alternative care choices have popped up that may meet the short-term needs of this population. In some Hispanic areas, “medical” clinics that operate on a cash basis have cropped up in garages and homes. The very nature of these clinics has placed them outside of traditional regulatory scrutiny, putting this fragile population further in jeopardy.

In the true tradition of American enterprise, new “minute clinics” are starting to show up in supermarkets (e.g., ShopRite, Piggly Wiggly, Wal-Mart) and in pharmacies (e.g., Rite Aid, Walgreens, Duane Reade). In these locations—for a set fee of about $39-$49 per visit—patients can get quick, straightforward care where they shop, usually from a physician assistant or a nurse practitioner, with physician supervision offsite. Estimates are that there are currently more than 150 such retailed-based health clinics, treating non-urgent health conditions, around the country today. And with demand high, it is expected that these will continue to blossom.

Implications for Primary Care and the Health System

Will these minute clinics become the treatment choice for the cash patient? Will they encroach on traditional primary care? Will an ever-increasing part of the population see healthcare in bursts, in snapshots of care provided in shopping malls, or—for the acutely ill—in emergency departments and subsequently in hospitals? When so much is known about the economies of preventive care—not to mention the value in reducing morbidity and mortality for the individual—and with the predictive value of the genome on the horizon, does the trend to push so many people out of the traditional system, simply because of lack of funding, make sense to anyone?

Implications for Business and America’s Future

Businesses are caught in a bind. They do not have the revenue to absorb double-digit increases in insurance premiums. They are faced with the difficult choice of either reducing benefits to their workers or reducing their work force. By reducing or eliminating health insurance benefits, however, they potentially damage the very workforce they need to keep healthy—and not distracted by the health of their families—in order to be competitive in a global market.

American businesses have shouldered the burden of paying for healthcare in many ways. They pay directly for employee health benefits and workers’ compensation. By paying taxes, they fund Medicare and Medicaid. Many businesses shoulder additional burdens from previous union contracts for benefits for retired employees. All of this comes about in a global market in which many of their foreign competitors cover a much smaller portion of their countries’ health bills.

In the end, I am convinced that hospitalists and all hospital professionals, along with many other physicians, will step into the breach and provide the best healthcare quality they can, regardless of the patient’s ability to pay for the care. That is just what we do. But the time has come for those of us who think and act on the nation’s health problems, who should have a longer term and more global view, to step out and step up to change a system that is currently leaving almost 50 million Americans on the side of the road.

I simply ask the question, “If not us, who?” TH

Dr. Wellikson has been CEO of SHM since 2000.

The byproduct of tighter bottom lines for America’s industry is the big squeeze in health benefits. Those still lucky enough to have employer-based insurance coverage most likely have higher deductibles and co-pays or have been shifted to plans with a limited choice of providers. For those 1.3 million who have become uninsured in the past year, welcome to the growing legions of working class Americans who are “going bare” and hoping for good health.

As the chart below indicates, data just released from the government shows the steady and relentless rise in our country’s uninsured population.

This past year we have added 1.3 million new Americans to this very vulnerable group. And many of these people work full time.

Rethinking Your Stereotype of the Uninsured

Let me help you discard your stereotypes regarding the uninsured. Many are the working poor. They are caught in that dangerous economic wasteland between poverty and unemployment with the benefits of Medicaid and the ability to purchase affordable health insurance that will leave them with enough left over to feed, clothe, and house their families.

There are 37.8 million Americans of working age without insurance, and 27.3 million of them actually had paying jobs for some or all of last year. Even more astounding, the number of uninsured full-time workers grew by 1 million, from 20.5 million in 2004 to 21.5 million in 2005. Only 27.3% of uninsured Americans did not work at all.

This is not solely a problem for the poor and uneducated. More than 5 million of the uninsured had a college degree, more than 15 million had attended college at one time, and 22.6% had household incomes of more than $50,000 a year.

This is a particular problem for young Americans. Almost 70% of the uninsured are under 35 years of age. Even more disturbing, the number of children without insurance coverage rose from 7.9 million in 2004 to 8.3 million in 2005. This phenomenon occurred despite a number of legislative efforts to cover children and the allocation of extra resources in many states for sign-up drives organized to enroll more children.

The racial makeup of the uninsured population may surprise you as well. More than 22 million uninsured are non-Hispanic whites. In an emergent trend, however, an increasing percentage of the uninsured are Hispanic. There are now more than 14 million uninsured Hispanics in this country, representing a growing percentage of the Hispanic population in states such as California and Texas.

Implications for Hospitals and Hospitalists

Like emergency department physicians, hospitalists are hospital-based and ready to take all comers—regardless of insurance coverage or ability to pay the bills. On the clinical side, it is well known that those without insurance coverage generally avoid outpatient services that might have prevented an acute hospitalization. In addition, there is more often a chance for a falloff in post-discharge medical follow-up in those who lack insurance and a supportive outpatient physician. This can lead to unnecessary morbidity and readmissions.

For hospitals, finding a specialist to manage the patients in the emergency department or to co-manage with the hospitalist upon admission creates an additional strain. Depending on the hospital’s locale and patient mix, any increase in patients who are “self pay,” or uninsured, creates a financial strain that can affect the hospitalist service, as well as other hospital-supported clinical functions.

Implications for Patients

Some people with no insurance coverage just won’t get healthcare until they are in extremis—a costly choice for the patient’s well being and longevity, as well as for the entire health system.

More recently, alternative care choices have popped up that may meet the short-term needs of this population. In some Hispanic areas, “medical” clinics that operate on a cash basis have cropped up in garages and homes. The very nature of these clinics has placed them outside of traditional regulatory scrutiny, putting this fragile population further in jeopardy.

In the true tradition of American enterprise, new “minute clinics” are starting to show up in supermarkets (e.g., ShopRite, Piggly Wiggly, Wal-Mart) and in pharmacies (e.g., Rite Aid, Walgreens, Duane Reade). In these locations—for a set fee of about $39-$49 per visit—patients can get quick, straightforward care where they shop, usually from a physician assistant or a nurse practitioner, with physician supervision offsite. Estimates are that there are currently more than 150 such retailed-based health clinics, treating non-urgent health conditions, around the country today. And with demand high, it is expected that these will continue to blossom.

Implications for Primary Care and the Health System

Will these minute clinics become the treatment choice for the cash patient? Will they encroach on traditional primary care? Will an ever-increasing part of the population see healthcare in bursts, in snapshots of care provided in shopping malls, or—for the acutely ill—in emergency departments and subsequently in hospitals? When so much is known about the economies of preventive care—not to mention the value in reducing morbidity and mortality for the individual—and with the predictive value of the genome on the horizon, does the trend to push so many people out of the traditional system, simply because of lack of funding, make sense to anyone?

Implications for Business and America’s Future

Businesses are caught in a bind. They do not have the revenue to absorb double-digit increases in insurance premiums. They are faced with the difficult choice of either reducing benefits to their workers or reducing their work force. By reducing or eliminating health insurance benefits, however, they potentially damage the very workforce they need to keep healthy—and not distracted by the health of their families—in order to be competitive in a global market.

American businesses have shouldered the burden of paying for healthcare in many ways. They pay directly for employee health benefits and workers’ compensation. By paying taxes, they fund Medicare and Medicaid. Many businesses shoulder additional burdens from previous union contracts for benefits for retired employees. All of this comes about in a global market in which many of their foreign competitors cover a much smaller portion of their countries’ health bills.

In the end, I am convinced that hospitalists and all hospital professionals, along with many other physicians, will step into the breach and provide the best healthcare quality they can, regardless of the patient’s ability to pay for the care. That is just what we do. But the time has come for those of us who think and act on the nation’s health problems, who should have a longer term and more global view, to step out and step up to change a system that is currently leaving almost 50 million Americans on the side of the road.

I simply ask the question, “If not us, who?” TH

Dr. Wellikson has been CEO of SHM since 2000.

The byproduct of tighter bottom lines for America’s industry is the big squeeze in health benefits. Those still lucky enough to have employer-based insurance coverage most likely have higher deductibles and co-pays or have been shifted to plans with a limited choice of providers. For those 1.3 million who have become uninsured in the past year, welcome to the growing legions of working class Americans who are “going bare” and hoping for good health.

As the chart below indicates, data just released from the government shows the steady and relentless rise in our country’s uninsured population.

This past year we have added 1.3 million new Americans to this very vulnerable group. And many of these people work full time.

Rethinking Your Stereotype of the Uninsured

Let me help you discard your stereotypes regarding the uninsured. Many are the working poor. They are caught in that dangerous economic wasteland between poverty and unemployment with the benefits of Medicaid and the ability to purchase affordable health insurance that will leave them with enough left over to feed, clothe, and house their families.

There are 37.8 million Americans of working age without insurance, and 27.3 million of them actually had paying jobs for some or all of last year. Even more astounding, the number of uninsured full-time workers grew by 1 million, from 20.5 million in 2004 to 21.5 million in 2005. Only 27.3% of uninsured Americans did not work at all.

This is not solely a problem for the poor and uneducated. More than 5 million of the uninsured had a college degree, more than 15 million had attended college at one time, and 22.6% had household incomes of more than $50,000 a year.

This is a particular problem for young Americans. Almost 70% of the uninsured are under 35 years of age. Even more disturbing, the number of children without insurance coverage rose from 7.9 million in 2004 to 8.3 million in 2005. This phenomenon occurred despite a number of legislative efforts to cover children and the allocation of extra resources in many states for sign-up drives organized to enroll more children.

The racial makeup of the uninsured population may surprise you as well. More than 22 million uninsured are non-Hispanic whites. In an emergent trend, however, an increasing percentage of the uninsured are Hispanic. There are now more than 14 million uninsured Hispanics in this country, representing a growing percentage of the Hispanic population in states such as California and Texas.

Implications for Hospitals and Hospitalists

Like emergency department physicians, hospitalists are hospital-based and ready to take all comers—regardless of insurance coverage or ability to pay the bills. On the clinical side, it is well known that those without insurance coverage generally avoid outpatient services that might have prevented an acute hospitalization. In addition, there is more often a chance for a falloff in post-discharge medical follow-up in those who lack insurance and a supportive outpatient physician. This can lead to unnecessary morbidity and readmissions.

For hospitals, finding a specialist to manage the patients in the emergency department or to co-manage with the hospitalist upon admission creates an additional strain. Depending on the hospital’s locale and patient mix, any increase in patients who are “self pay,” or uninsured, creates a financial strain that can affect the hospitalist service, as well as other hospital-supported clinical functions.

Implications for Patients

Some people with no insurance coverage just won’t get healthcare until they are in extremis—a costly choice for the patient’s well being and longevity, as well as for the entire health system.

More recently, alternative care choices have popped up that may meet the short-term needs of this population. In some Hispanic areas, “medical” clinics that operate on a cash basis have cropped up in garages and homes. The very nature of these clinics has placed them outside of traditional regulatory scrutiny, putting this fragile population further in jeopardy.

In the true tradition of American enterprise, new “minute clinics” are starting to show up in supermarkets (e.g., ShopRite, Piggly Wiggly, Wal-Mart) and in pharmacies (e.g., Rite Aid, Walgreens, Duane Reade). In these locations—for a set fee of about $39-$49 per visit—patients can get quick, straightforward care where they shop, usually from a physician assistant or a nurse practitioner, with physician supervision offsite. Estimates are that there are currently more than 150 such retailed-based health clinics, treating non-urgent health conditions, around the country today. And with demand high, it is expected that these will continue to blossom.

Implications for Primary Care and the Health System

Will these minute clinics become the treatment choice for the cash patient? Will they encroach on traditional primary care? Will an ever-increasing part of the population see healthcare in bursts, in snapshots of care provided in shopping malls, or—for the acutely ill—in emergency departments and subsequently in hospitals? When so much is known about the economies of preventive care—not to mention the value in reducing morbidity and mortality for the individual—and with the predictive value of the genome on the horizon, does the trend to push so many people out of the traditional system, simply because of lack of funding, make sense to anyone?

Implications for Business and America’s Future

Businesses are caught in a bind. They do not have the revenue to absorb double-digit increases in insurance premiums. They are faced with the difficult choice of either reducing benefits to their workers or reducing their work force. By reducing or eliminating health insurance benefits, however, they potentially damage the very workforce they need to keep healthy—and not distracted by the health of their families—in order to be competitive in a global market.

American businesses have shouldered the burden of paying for healthcare in many ways. They pay directly for employee health benefits and workers’ compensation. By paying taxes, they fund Medicare and Medicaid. Many businesses shoulder additional burdens from previous union contracts for benefits for retired employees. All of this comes about in a global market in which many of their foreign competitors cover a much smaller portion of their countries’ health bills.

In the end, I am convinced that hospitalists and all hospital professionals, along with many other physicians, will step into the breach and provide the best healthcare quality they can, regardless of the patient’s ability to pay for the care. That is just what we do. But the time has come for those of us who think and act on the nation’s health problems, who should have a longer term and more global view, to step out and step up to change a system that is currently leaving almost 50 million Americans on the side of the road.

I simply ask the question, “If not us, who?” TH

Dr. Wellikson has been CEO of SHM since 2000.

We are now knee deep in the quality revolution. In some ways, this should have been driven by the hospitals and doctors striving for continual quality improvement. It should have been driven by patients demanding better outcomes, more uniform processes, and the data to help them decide where to receive the best care. In reality it is being driven by those who pay for care—America’s businesses and our government, two entities that want better value for the increasingly dear dollars they spend on healthcare.

Hospitals and doctors have survived (and many have succeeded) by using the traditional compensation system, which rewards the performing of care without rewarding the best or even the better practice of medicine. Today you can do the wrong procedure and do it poorly and still get paid. The mantra of the entire performance and standards effort is to shift at least some of the rewards to those with better outcomes, to processes that are more in line with national practice standards, and to those who have the data to back that up. In marketing shorthand, this is pay for performance—or P4P—and while it seems natural in most of the rest of the American marketplace, it is somewhat revolutionary in healthcare.

While the concept of identifying best practices, measuring performance, collecting data, and then appropriately tying compensation or rewards to performance sounds clear and straightforward, many issues quickly surface to cloud any forward progress.

Decide What to Measure

Unfortunately, you can arrive quickly and efficiently at the wrong destination. Everyone knows that some of the hallmarks of physicians are that we can “perform for the test” and adapt to a new paradigm. It is important that we don’t just settle for what we can easily measure (knowing that most of our systems’ data collection efforts are geared initially to getting paid and not to measuring key performance indicators), but that we make sure that we are selecting performance measures that lead to better patient outcomes and improve care. Hospitalists must constantly examine their hospitals’ plans for data collection to ensure that achieving high marks will lead to better patient care.

Data, Data, Who Gets the Data?

There is no doubt that the by-product of the current P4P movement is that there will be more known about doctors and hospitals than ever before. Like nuclear energy, this volatile resource can be used for good or evil. It is not a trivial issue of who “owns” the data and who has access to it.

How valuable would it be to the pharmaceutical industry to know which doctors treat a lot of heart failure and which medications they use and why? How valuable would it be for insurance companies to see physician or hospital performance data not just for their insured, but for all of a physician’s or institution’s patients? Who will control access to all the data that will be collected?

This plays into another important question: Just how will individual or small independent groups of physicians pay for all this reporting? Very likely, data collection and reporting will be an additional cost of doing business for an already strapped profession. To succeed—or just to stay in the game—physicians will need to upgrade their systems with new hardware and software, while facing the prospect of having their payment diminished or of being cut off from certain patients. What if a hospital offered physicians free systems upgrades in exchange for a look at all the physicians’ data? What if pharmaceutical companies made the same offer? Would physicians potentially sell their information for a handful of beads?

Where to Be? What to Do?

For national professional societies, the greater issue may be how best to participate proactively in the P4P process and how to define their roles. Should SHM be involved in developing new standards of care for areas where we have crucial roles (e.g., transitions of care, end-of-life care) or should we simply critique the efforts of others? Is our role to be the patients’ advocate at any cost, or do we have a responsibility to stand up for the young and evolving discipline of hospital medicine? Is SHM’s main role to be a communicator to our nation’s hospitalists about what the new rules and standards will be, or should SHM develop educational resources to help hospitalists act as leaders in the implementation of the rules that flow out of this complex process?

Just as important is to try to understand where SHM can be most effective. As hospitals have seen a huge growth in the data they must collect and report on, so too has SHM observed a proliferation of organizations cropping up to take their place as key players in the P4P arena. SHM can’t be everywhere, so we have chosen to enter where we feel we can make the most impact.

Hospitalists’ Role in Improving Quality

First, SHM has created a working group on Performance and Standards to coordinate all of our relationships in this rapidly evolving and growing field. SHM has hired Jill Epstein to be the dedicated staff for this effort. SHM has decided to actively participate with the AMA Physician Consortium for Performance Improvement (PCPI) because this is where most of the specialties of medicine come together to develop and assess performance standards.

SHM is also becoming more active at the National Quality Forum (NQF), where groups such as the PCPI submit their standards for acceptance. SHM has nominated hospital medicine leaders for the NQF Steering Committee as well as for its Technical Advisory Panels on Patient Safety, Anesthesia and Surgery, and Pediatrics. The Centers for Medicare and Medicaid Services and Congress will look to NQF as a national clearinghouse for performance measurements.

SHM has had a good working relationship with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for years. Now, SHM looks to expand our work with JCAHO as their role in standard setting and accreditation evolves.

In this complex arena, SHM is constantly looking for other professional medical societies with similar interests and values with which to share information and strategies. SHM has found the American College of Physicians, the American Geriatrics Society, the Society of Critical Care Medicine, the American College of Chest Physicians (ACCP), and others particularly open and helpful.

But SHM won’t be content with just helping to set the standards. We believe hospitalists have a unique role in implementing change. Beginning with our Leadership Academies, which train those who can lead and manage change, SHM has also introduced a quality improvement precourse at our annual meetings, as well as the practical Resource Rooms on our Web site, which have 100-page detailed workbooks to guide hospitalist leaders in quality improvement projects in DVT and diabetes. Under the leadership of Greg Maynard, MD, of University of California at San Diego (UCSD) and Jason Stein, MD, of Emory University Hospital, Atlanta, with staff leadership by Kathleen Kerr of UCSF, SHM has just launched its DVT Mentored Implementation project, in which we will guide, support, and mentor 30 hospital medicine leaders to improve patient care at their local institutions.

SHM is actively partnering with the Institute for Healthcare Improvement (IHI) to train and support the hospitalists who will leverage IHI’s “100K Lives Saved” campaign. These hospitalist leaders will act as change agents for further quality improvements on a local level.

Not a Time to Stand Idly By

The status quo is not an option. This call for change is, in many ways, fueling the growth of hospital medicine. Change that was called for many years ago is now taking shape. SHM is playing a role in ensuring that the new standards of care that we will have to meet make sense to improve the care our patients receive. But SHM won’t just set the rules, line the field, and build the scoreboard. Spring training—a time when we will need to refine old skills and develop new ones—is upon us. Hospitalists are ready to play their part. Game on. Let’s go. TH

Dr. Wellikson has been CEO of SHM since 2000.

We are now knee deep in the quality revolution. In some ways, this should have been driven by the hospitals and doctors striving for continual quality improvement. It should have been driven by patients demanding better outcomes, more uniform processes, and the data to help them decide where to receive the best care. In reality it is being driven by those who pay for care—America’s businesses and our government, two entities that want better value for the increasingly dear dollars they spend on healthcare.

Hospitals and doctors have survived (and many have succeeded) by using the traditional compensation system, which rewards the performing of care without rewarding the best or even the better practice of medicine. Today you can do the wrong procedure and do it poorly and still get paid. The mantra of the entire performance and standards effort is to shift at least some of the rewards to those with better outcomes, to processes that are more in line with national practice standards, and to those who have the data to back that up. In marketing shorthand, this is pay for performance—or P4P—and while it seems natural in most of the rest of the American marketplace, it is somewhat revolutionary in healthcare.

While the concept of identifying best practices, measuring performance, collecting data, and then appropriately tying compensation or rewards to performance sounds clear and straightforward, many issues quickly surface to cloud any forward progress.

Decide What to Measure

Unfortunately, you can arrive quickly and efficiently at the wrong destination. Everyone knows that some of the hallmarks of physicians are that we can “perform for the test” and adapt to a new paradigm. It is important that we don’t just settle for what we can easily measure (knowing that most of our systems’ data collection efforts are geared initially to getting paid and not to measuring key performance indicators), but that we make sure that we are selecting performance measures that lead to better patient outcomes and improve care. Hospitalists must constantly examine their hospitals’ plans for data collection to ensure that achieving high marks will lead to better patient care.

Data, Data, Who Gets the Data?

There is no doubt that the by-product of the current P4P movement is that there will be more known about doctors and hospitals than ever before. Like nuclear energy, this volatile resource can be used for good or evil. It is not a trivial issue of who “owns” the data and who has access to it.

How valuable would it be to the pharmaceutical industry to know which doctors treat a lot of heart failure and which medications they use and why? How valuable would it be for insurance companies to see physician or hospital performance data not just for their insured, but for all of a physician’s or institution’s patients? Who will control access to all the data that will be collected?

This plays into another important question: Just how will individual or small independent groups of physicians pay for all this reporting? Very likely, data collection and reporting will be an additional cost of doing business for an already strapped profession. To succeed—or just to stay in the game—physicians will need to upgrade their systems with new hardware and software, while facing the prospect of having their payment diminished or of being cut off from certain patients. What if a hospital offered physicians free systems upgrades in exchange for a look at all the physicians’ data? What if pharmaceutical companies made the same offer? Would physicians potentially sell their information for a handful of beads?

Where to Be? What to Do?

For national professional societies, the greater issue may be how best to participate proactively in the P4P process and how to define their roles. Should SHM be involved in developing new standards of care for areas where we have crucial roles (e.g., transitions of care, end-of-life care) or should we simply critique the efforts of others? Is our role to be the patients’ advocate at any cost, or do we have a responsibility to stand up for the young and evolving discipline of hospital medicine? Is SHM’s main role to be a communicator to our nation’s hospitalists about what the new rules and standards will be, or should SHM develop educational resources to help hospitalists act as leaders in the implementation of the rules that flow out of this complex process?

Just as important is to try to understand where SHM can be most effective. As hospitals have seen a huge growth in the data they must collect and report on, so too has SHM observed a proliferation of organizations cropping up to take their place as key players in the P4P arena. SHM can’t be everywhere, so we have chosen to enter where we feel we can make the most impact.

Hospitalists’ Role in Improving Quality

First, SHM has created a working group on Performance and Standards to coordinate all of our relationships in this rapidly evolving and growing field. SHM has hired Jill Epstein to be the dedicated staff for this effort. SHM has decided to actively participate with the AMA Physician Consortium for Performance Improvement (PCPI) because this is where most of the specialties of medicine come together to develop and assess performance standards.

SHM is also becoming more active at the National Quality Forum (NQF), where groups such as the PCPI submit their standards for acceptance. SHM has nominated hospital medicine leaders for the NQF Steering Committee as well as for its Technical Advisory Panels on Patient Safety, Anesthesia and Surgery, and Pediatrics. The Centers for Medicare and Medicaid Services and Congress will look to NQF as a national clearinghouse for performance measurements.

SHM has had a good working relationship with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for years. Now, SHM looks to expand our work with JCAHO as their role in standard setting and accreditation evolves.

In this complex arena, SHM is constantly looking for other professional medical societies with similar interests and values with which to share information and strategies. SHM has found the American College of Physicians, the American Geriatrics Society, the Society of Critical Care Medicine, the American College of Chest Physicians (ACCP), and others particularly open and helpful.

But SHM won’t be content with just helping to set the standards. We believe hospitalists have a unique role in implementing change. Beginning with our Leadership Academies, which train those who can lead and manage change, SHM has also introduced a quality improvement precourse at our annual meetings, as well as the practical Resource Rooms on our Web site, which have 100-page detailed workbooks to guide hospitalist leaders in quality improvement projects in DVT and diabetes. Under the leadership of Greg Maynard, MD, of University of California at San Diego (UCSD) and Jason Stein, MD, of Emory University Hospital, Atlanta, with staff leadership by Kathleen Kerr of UCSF, SHM has just launched its DVT Mentored Implementation project, in which we will guide, support, and mentor 30 hospital medicine leaders to improve patient care at their local institutions.

SHM is actively partnering with the Institute for Healthcare Improvement (IHI) to train and support the hospitalists who will leverage IHI’s “100K Lives Saved” campaign. These hospitalist leaders will act as change agents for further quality improvements on a local level.

Not a Time to Stand Idly By

The status quo is not an option. This call for change is, in many ways, fueling the growth of hospital medicine. Change that was called for many years ago is now taking shape. SHM is playing a role in ensuring that the new standards of care that we will have to meet make sense to improve the care our patients receive. But SHM won’t just set the rules, line the field, and build the scoreboard. Spring training—a time when we will need to refine old skills and develop new ones—is upon us. Hospitalists are ready to play their part. Game on. Let’s go. TH

Dr. Wellikson has been CEO of SHM since 2000.

We are now knee deep in the quality revolution. In some ways, this should have been driven by the hospitals and doctors striving for continual quality improvement. It should have been driven by patients demanding better outcomes, more uniform processes, and the data to help them decide where to receive the best care. In reality it is being driven by those who pay for care—America’s businesses and our government, two entities that want better value for the increasingly dear dollars they spend on healthcare.

Hospitals and doctors have survived (and many have succeeded) by using the traditional compensation system, which rewards the performing of care without rewarding the best or even the better practice of medicine. Today you can do the wrong procedure and do it poorly and still get paid. The mantra of the entire performance and standards effort is to shift at least some of the rewards to those with better outcomes, to processes that are more in line with national practice standards, and to those who have the data to back that up. In marketing shorthand, this is pay for performance—or P4P—and while it seems natural in most of the rest of the American marketplace, it is somewhat revolutionary in healthcare.

While the concept of identifying best practices, measuring performance, collecting data, and then appropriately tying compensation or rewards to performance sounds clear and straightforward, many issues quickly surface to cloud any forward progress.

Decide What to Measure

Unfortunately, you can arrive quickly and efficiently at the wrong destination. Everyone knows that some of the hallmarks of physicians are that we can “perform for the test” and adapt to a new paradigm. It is important that we don’t just settle for what we can easily measure (knowing that most of our systems’ data collection efforts are geared initially to getting paid and not to measuring key performance indicators), but that we make sure that we are selecting performance measures that lead to better patient outcomes and improve care. Hospitalists must constantly examine their hospitals’ plans for data collection to ensure that achieving high marks will lead to better patient care.

Data, Data, Who Gets the Data?

There is no doubt that the by-product of the current P4P movement is that there will be more known about doctors and hospitals than ever before. Like nuclear energy, this volatile resource can be used for good or evil. It is not a trivial issue of who “owns” the data and who has access to it.

How valuable would it be to the pharmaceutical industry to know which doctors treat a lot of heart failure and which medications they use and why? How valuable would it be for insurance companies to see physician or hospital performance data not just for their insured, but for all of a physician’s or institution’s patients? Who will control access to all the data that will be collected?

This plays into another important question: Just how will individual or small independent groups of physicians pay for all this reporting? Very likely, data collection and reporting will be an additional cost of doing business for an already strapped profession. To succeed—or just to stay in the game—physicians will need to upgrade their systems with new hardware and software, while facing the prospect of having their payment diminished or of being cut off from certain patients. What if a hospital offered physicians free systems upgrades in exchange for a look at all the physicians’ data? What if pharmaceutical companies made the same offer? Would physicians potentially sell their information for a handful of beads?

Where to Be? What to Do?

For national professional societies, the greater issue may be how best to participate proactively in the P4P process and how to define their roles. Should SHM be involved in developing new standards of care for areas where we have crucial roles (e.g., transitions of care, end-of-life care) or should we simply critique the efforts of others? Is our role to be the patients’ advocate at any cost, or do we have a responsibility to stand up for the young and evolving discipline of hospital medicine? Is SHM’s main role to be a communicator to our nation’s hospitalists about what the new rules and standards will be, or should SHM develop educational resources to help hospitalists act as leaders in the implementation of the rules that flow out of this complex process?

Just as important is to try to understand where SHM can be most effective. As hospitals have seen a huge growth in the data they must collect and report on, so too has SHM observed a proliferation of organizations cropping up to take their place as key players in the P4P arena. SHM can’t be everywhere, so we have chosen to enter where we feel we can make the most impact.

Hospitalists’ Role in Improving Quality

First, SHM has created a working group on Performance and Standards to coordinate all of our relationships in this rapidly evolving and growing field. SHM has hired Jill Epstein to be the dedicated staff for this effort. SHM has decided to actively participate with the AMA Physician Consortium for Performance Improvement (PCPI) because this is where most of the specialties of medicine come together to develop and assess performance standards.

SHM is also becoming more active at the National Quality Forum (NQF), where groups such as the PCPI submit their standards for acceptance. SHM has nominated hospital medicine leaders for the NQF Steering Committee as well as for its Technical Advisory Panels on Patient Safety, Anesthesia and Surgery, and Pediatrics. The Centers for Medicare and Medicaid Services and Congress will look to NQF as a national clearinghouse for performance measurements.

SHM has had a good working relationship with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for years. Now, SHM looks to expand our work with JCAHO as their role in standard setting and accreditation evolves.

In this complex arena, SHM is constantly looking for other professional medical societies with similar interests and values with which to share information and strategies. SHM has found the American College of Physicians, the American Geriatrics Society, the Society of Critical Care Medicine, the American College of Chest Physicians (ACCP), and others particularly open and helpful.

But SHM won’t be content with just helping to set the standards. We believe hospitalists have a unique role in implementing change. Beginning with our Leadership Academies, which train those who can lead and manage change, SHM has also introduced a quality improvement precourse at our annual meetings, as well as the practical Resource Rooms on our Web site, which have 100-page detailed workbooks to guide hospitalist leaders in quality improvement projects in DVT and diabetes. Under the leadership of Greg Maynard, MD, of University of California at San Diego (UCSD) and Jason Stein, MD, of Emory University Hospital, Atlanta, with staff leadership by Kathleen Kerr of UCSF, SHM has just launched its DVT Mentored Implementation project, in which we will guide, support, and mentor 30 hospital medicine leaders to improve patient care at their local institutions.

SHM is actively partnering with the Institute for Healthcare Improvement (IHI) to train and support the hospitalists who will leverage IHI’s “100K Lives Saved” campaign. These hospitalist leaders will act as change agents for further quality improvements on a local level.

Not a Time to Stand Idly By

The status quo is not an option. This call for change is, in many ways, fueling the growth of hospital medicine. Change that was called for many years ago is now taking shape. SHM is playing a role in ensuring that the new standards of care that we will have to meet make sense to improve the care our patients receive. But SHM won’t just set the rules, line the field, and build the scoreboard. Spring training—a time when we will need to refine old skills and develop new ones—is upon us. Hospitalists are ready to play their part. Game on. Let’s go. TH

Dr. Wellikson has been CEO of SHM since 2000.

While many of you associate me with hospital medicine and SHM, this is only my latest incarnation. For more than 15 years I was a practicing solo general internist in Southern California. You remember me as one of those local medical doctors (LMDs), who stopped by the hospital on the way to their office in the tall office building next to the community hospital where they worked from 9-12 and 2-5 and then went back to the hospital to see admissions and do consults for surgeons.

Right out of training in the 1970s I was the complete internist. I managed my own vents, did my own lumbar punctures, bone marrows, and arterial lines. I prided myself on being well versed in enough of the medical specialties that I was my own internal consultant and the first line of consultation and advice for local surgeons and family practitioners (FPs).

I should also reveal that I played a role first on the board of directors of the American Society of Internal Medicine (ASIM) and then on the board of regents of the American College of Physicians (ACP). I was in the vicinity when RBRVS (resource based relative value system) was born and when internists devolved into gatekeepers and primary care physicians.

I saw the internist as the master detective, but somehow we were recast as the cop on the beat very much on the front lines. From solving the great mysteries we were now settling domestic squabbles and writing traffic tickets. OK we were filling out forms for durable medical goods and writing prescriptions for antidepressants.

General internal medicine had a chance to define itself as comprising physicians who were master diagnosticians, the only doctors capable of handling the complexities of comorbidities, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with FPs and nurse practitioners (NPs) to be the traffic cop for resource use and burgeoning specialization.

Internal medicine has always been at a monetary disadvantage to the technospecialties of procedures and gadgets. But at least in the pre-primary care physician (PCP) world, internists could boast they were the “doctors’ doctors,” ready to take on the difficult and the complex. When we cast our lots with the gatekeepers, we became pieceworkers and paper shufflers. We made the excitement of internal medicine—the use of our skills of diagnosis and information integration—something to be avoided because of their very complexity. We created a situation in which the patients who most needed our services were disadvantageous in a world that devalued our training and wanted us to be more like the practical and efficient NPs.

Hospital medicine has come along to tap into the skills of internal medicine in the acute care setting. Hospital medicine strips away the PCP and gatekeeper functions, leaving us with the core of what drew many of us to internal medicine in the first place. As hospital medicine attempts to evolve into what the health system and our patients need, there are glimpses of what a “new” internist might be.

Clinical knowledge and bedside skills are still in demand. The ability to integrate information and see through complexity to formulate a diagnostic plan and a treatment protocol still define internal medicine. But the skills for the 21st-century internists now include data collection, quality improvement, systems analysis, teamwork, management, and leadership.

Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.

But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.

There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)

Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.

We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.

Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.

If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.

I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH

Dr. Wellikson has been CEO of SHM since 2000.

While many of you associate me with hospital medicine and SHM, this is only my latest incarnation. For more than 15 years I was a practicing solo general internist in Southern California. You remember me as one of those local medical doctors (LMDs), who stopped by the hospital on the way to their office in the tall office building next to the community hospital where they worked from 9-12 and 2-5 and then went back to the hospital to see admissions and do consults for surgeons.

Right out of training in the 1970s I was the complete internist. I managed my own vents, did my own lumbar punctures, bone marrows, and arterial lines. I prided myself on being well versed in enough of the medical specialties that I was my own internal consultant and the first line of consultation and advice for local surgeons and family practitioners (FPs).

I should also reveal that I played a role first on the board of directors of the American Society of Internal Medicine (ASIM) and then on the board of regents of the American College of Physicians (ACP). I was in the vicinity when RBRVS (resource based relative value system) was born and when internists devolved into gatekeepers and primary care physicians.

I saw the internist as the master detective, but somehow we were recast as the cop on the beat very much on the front lines. From solving the great mysteries we were now settling domestic squabbles and writing traffic tickets. OK we were filling out forms for durable medical goods and writing prescriptions for antidepressants.

General internal medicine had a chance to define itself as comprising physicians who were master diagnosticians, the only doctors capable of handling the complexities of comorbidities, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with FPs and nurse practitioners (NPs) to be the traffic cop for resource use and burgeoning specialization.

Internal medicine has always been at a monetary disadvantage to the technospecialties of procedures and gadgets. But at least in the pre-primary care physician (PCP) world, internists could boast they were the “doctors’ doctors,” ready to take on the difficult and the complex. When we cast our lots with the gatekeepers, we became pieceworkers and paper shufflers. We made the excitement of internal medicine—the use of our skills of diagnosis and information integration—something to be avoided because of their very complexity. We created a situation in which the patients who most needed our services were disadvantageous in a world that devalued our training and wanted us to be more like the practical and efficient NPs.

Hospital medicine has come along to tap into the skills of internal medicine in the acute care setting. Hospital medicine strips away the PCP and gatekeeper functions, leaving us with the core of what drew many of us to internal medicine in the first place. As hospital medicine attempts to evolve into what the health system and our patients need, there are glimpses of what a “new” internist might be.

Clinical knowledge and bedside skills are still in demand. The ability to integrate information and see through complexity to formulate a diagnostic plan and a treatment protocol still define internal medicine. But the skills for the 21st-century internists now include data collection, quality improvement, systems analysis, teamwork, management, and leadership.

Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.

But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.

There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)

Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.

We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.

Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.

If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.

I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH

Dr. Wellikson has been CEO of SHM since 2000.

While many of you associate me with hospital medicine and SHM, this is only my latest incarnation. For more than 15 years I was a practicing solo general internist in Southern California. You remember me as one of those local medical doctors (LMDs), who stopped by the hospital on the way to their office in the tall office building next to the community hospital where they worked from 9-12 and 2-5 and then went back to the hospital to see admissions and do consults for surgeons.

Right out of training in the 1970s I was the complete internist. I managed my own vents, did my own lumbar punctures, bone marrows, and arterial lines. I prided myself on being well versed in enough of the medical specialties that I was my own internal consultant and the first line of consultation and advice for local surgeons and family practitioners (FPs).

I should also reveal that I played a role first on the board of directors of the American Society of Internal Medicine (ASIM) and then on the board of regents of the American College of Physicians (ACP). I was in the vicinity when RBRVS (resource based relative value system) was born and when internists devolved into gatekeepers and primary care physicians.

I saw the internist as the master detective, but somehow we were recast as the cop on the beat very much on the front lines. From solving the great mysteries we were now settling domestic squabbles and writing traffic tickets. OK we were filling out forms for durable medical goods and writing prescriptions for antidepressants.

General internal medicine had a chance to define itself as comprising physicians who were master diagnosticians, the only doctors capable of handling the complexities of comorbidities, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with FPs and nurse practitioners (NPs) to be the traffic cop for resource use and burgeoning specialization.

Internal medicine has always been at a monetary disadvantage to the technospecialties of procedures and gadgets. But at least in the pre-primary care physician (PCP) world, internists could boast they were the “doctors’ doctors,” ready to take on the difficult and the complex. When we cast our lots with the gatekeepers, we became pieceworkers and paper shufflers. We made the excitement of internal medicine—the use of our skills of diagnosis and information integration—something to be avoided because of their very complexity. We created a situation in which the patients who most needed our services were disadvantageous in a world that devalued our training and wanted us to be more like the practical and efficient NPs.

Hospital medicine has come along to tap into the skills of internal medicine in the acute care setting. Hospital medicine strips away the PCP and gatekeeper functions, leaving us with the core of what drew many of us to internal medicine in the first place. As hospital medicine attempts to evolve into what the health system and our patients need, there are glimpses of what a “new” internist might be.

Clinical knowledge and bedside skills are still in demand. The ability to integrate information and see through complexity to formulate a diagnostic plan and a treatment protocol still define internal medicine. But the skills for the 21st-century internists now include data collection, quality improvement, systems analysis, teamwork, management, and leadership.

Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.

But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.

There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)

Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.

We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.

Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.

If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.

I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH

Dr. Wellikson has been CEO of SHM since 2000.

Spring and summer are the seasons of hope and promise. A time when seedlings turn into harvests, when every baseball team has hope, when things seem fresh and new. Hospital medicine is a specialty of hope and promise, of better things in the future. Hospitalists have the potential to change the course of medical care in the acute setting. Right now there are glimmers of this promise turning into realities.

We are seeing centers of experimentation as healthcare institutions and their visionary leaders use their ideas and energies to pilot test what may eventually be common changes throughout the country.

First Hospital Medicine Unit Being Built

In Rockford, Ill., the first Hospital Medicine Unit in Illinois—and possibly the country—is under construction. With a heritage as one of the first hospital medicine groups in Illinois, Rockford Health System is no stranger to innovation. They are currently framing the physical plant for a 17-bed hospital medicine unit and putting this right next to an ICU.

This unit will incorporate many of the accoutrements central to the design elements from the Hospital of the Future project that SHM is involved in with JCAHO and the Robert Wood Johnson Foundation. This plays into the SHM vision of the hospital of the future as patient centered, built on measurable quality, and delivered by teams.

All the rooms will be private with a healing environment incorporating the values of aesthetics, including restful light and sound. The design is set to promote communication and contact between the healthcare team and the patients and their families.

This unit will enhance efficiencies and quality care by concentrating hospitalists’ patients on one dedicated unit. The intent is to use this physical environment to create and reinforce a stronger team approach among hospitalists, nurses, pharmacists, therapists, and the rest of the healthcare team. There will be an opportunity to pilot new technology and treatment protocols to find out what works and what doesn’t. There will also be an opportunity to increase patient and family satisfaction.

As Lars Armainsson, chairman of the Rockford Hospital Medicine Department, says, “We’re pioneers in the way that we are transforming the way care is delivered, using the most advanced and sophisticated practice model to accommodate the 21st century.”

SHM, the rest of hospital medicine, and the C-suite of other hospitals will be waiting to hear how the Rockford Hospital Medicine Unit plays out. We hope the lessons learned there will soon provide a beacon of clarity for others to follow.

Three-Year Hospital Medicine Residency Track

The crisis in internal medicine residency training and the poor results in the recent intern match have at least one internal medicine residency program taking extreme measures to redesign and remarket its program to today’s medical students.

A residency program director in the West has contacted SHM about the feasibility of creating the first internal medicine residency to train only future hospitalists. This program has experienced more than 75% of its recent graduates going into hospital medicine careers. The program leaders also believe that with a continually shrinking pool of applicants for all of internal medicine their resident recruitment would be enhanced if they marketed their residency as a dedicated training program for the future hospitalists; cardiologists and outpatient internists need not apply.

The program leaders envision basing the new internal medicine residency curriculum on the SHM Core Competencies in Hospital Medicine and meeting RRC requirements for 33% of the training being outpatient in focus by training the future hospitalists in working to help the emergency department physicians with decision making, opening an outpatient clinic for the first one to two post-discharge follow-up visits, and starting an IMPACT clinic (such as the one started by hospitalists at the Cleveland Clinic) to evaluate preoperative patients.

This new residency program would also promote training in systems approaches, epidemiology, quality improvement, information technology, team building, leadership, and management.

The hope is that by narrowing the focus, this residency can attract better applicants, focus the training on a specific type of future internist, and have their graduates viewed by hospitalist employers as very desirable candidates for future hospitalist jobs.

Obviously, this revolutionary approach is a delicate path to walk. Because this is an idea working its way through its home institution, I have agreed to be purposely vague about where this is being investigated for now. Like the executive leadership at Rockford Health System, if the leadership of this hospital and medical staff can be equally visionary, I expect they will be looking for SHM and everyone else to promote this unique internal medicine residency and get the word out.

Mentored Implementation for QI

Not to be left out, SHM is doing its part in creating innovations to move forward hospital medicine’s agenda of change.

SHM has recently obtained two years’ worth of support from The Sanofi-Aventis Group to create and implement a mentored process to develop the hospitalist leaders who will be trained to measure and improve the quality of care that their hospitals deliver—especially in DVT prevention and treatment. Once these skills are learned, we hope that the same precepts can be used for other disease states that hospitalists manage.

This approach is modeled on similar approaches that have been successful in extending the reach of palliative care training. SHM’s idea is to select 10 outstanding hospitalist leaders and train them to do two fundamental things:

1. Use SHM QI tools to measure and improve quality at their institutions; and
2. Be trained to mentor future hospitalist leaders.

SHM would then use these initial 10 mentors to train another 30 hospitalist leaders (three for each initial mentor) in QI and potentially as future mentors.

Using this initial two-year project as a learning guide for process improvement and to develop the first cadre of quality mentors, the next step might be to ask for support from a foundation such as Hartford Foundation or Robert Wood Johnson Foundation—or a governmental agency such as the Agency for Healthcare Quality and Research—for broader funding to expand this initiative to 100 or even 500 sites. The goal would be to create a framework that would develop a hospitalist leader trained to lead the quality initiatives at every hospital in the country.

There are other partnerships that SHM is exploring to make this a reality. Recently SHM senior staff and leadership traveled to Boston to meet with senior leadership at the Institute for Healthcare Improvement (IHI). During those meetings, IHI CEO Don Berwick called hospitalists the “army for quality improvement implementation in our nation’s hospitals.” Ambitious undertakings like SHM’s mentored implementation project will be needed to export the well-known and well-documented knowledge of quality improvement and translate this down to the bedside.

Hospital medicine today is much more potential than reality. The history of American innovation is littered with ideas that failed because of issues with scope, scalability, or poor timing. In an era calling for evidence-based medicine, accountability, measured quality, teamwork, and a renewed emphasis on the patient, there are many stakeholders in healthcare rooting for (and even counting on) hospital medicine to turn promise into performance. We must not let the perfect be the enemy of the good. The status quo is just not good enough, and we will need to be risk takers and adventuresome to achieve great things.

In his book Organizing Genius: The Secrets of Creative Collaboration, Warren Bennis explores the success of such diverse enterprises as the development by Apple of the Macintosh, the engineering mastery at Lockheed Martin’s Skunk Works of the stealth aircraft, the Manhattan Project that developed the nuclear bomb, and Disney’s creation of animated feature films (e.g., “Snow White”) and found that an adventurous spirit was critical element. Adventure was defined as “risk, jeopardy, a daring feat, encountering a hazardous enterprise.”

Hospital medicine is on no less of an adventure. The prize at the end of the journey is better healthcare for our communities. Hospitalists are the soldiers in this battle. Whether you are the general or the foot soldier, we must all help prevail. SHM will be there to do its part. TH

Dr. Wellikson has been CEO of SHM since 2000.

Spring and summer are the seasons of hope and promise. A time when seedlings turn into harvests, when every baseball team has hope, when things seem fresh and new. Hospital medicine is a specialty of hope and promise, of better things in the future. Hospitalists have the potential to change the course of medical care in the acute setting. Right now there are glimmers of this promise turning into realities.

We are seeing centers of experimentation as healthcare institutions and their visionary leaders use their ideas and energies to pilot test what may eventually be common changes throughout the country.

First Hospital Medicine Unit Being Built

In Rockford, Ill., the first Hospital Medicine Unit in Illinois—and possibly the country—is under construction. With a heritage as one of the first hospital medicine groups in Illinois, Rockford Health System is no stranger to innovation. They are currently framing the physical plant for a 17-bed hospital medicine unit and putting this right next to an ICU.

This unit will incorporate many of the accoutrements central to the design elements from the Hospital of the Future project that SHM is involved in with JCAHO and the Robert Wood Johnson Foundation. This plays into the SHM vision of the hospital of the future as patient centered, built on measurable quality, and delivered by teams.

All the rooms will be private with a healing environment incorporating the values of aesthetics, including restful light and sound. The design is set to promote communication and contact between the healthcare team and the patients and their families.

This unit will enhance efficiencies and quality care by concentrating hospitalists’ patients on one dedicated unit. The intent is to use this physical environment to create and reinforce a stronger team approach among hospitalists, nurses, pharmacists, therapists, and the rest of the healthcare team. There will be an opportunity to pilot new technology and treatment protocols to find out what works and what doesn’t. There will also be an opportunity to increase patient and family satisfaction.

As Lars Armainsson, chairman of the Rockford Hospital Medicine Department, says, “We’re pioneers in the way that we are transforming the way care is delivered, using the most advanced and sophisticated practice model to accommodate the 21st century.”

SHM, the rest of hospital medicine, and the C-suite of other hospitals will be waiting to hear how the Rockford Hospital Medicine Unit plays out. We hope the lessons learned there will soon provide a beacon of clarity for others to follow.

Three-Year Hospital Medicine Residency Track

The crisis in internal medicine residency training and the poor results in the recent intern match have at least one internal medicine residency program taking extreme measures to redesign and remarket its program to today’s medical students.

A residency program director in the West has contacted SHM about the feasibility of creating the first internal medicine residency to train only future hospitalists. This program has experienced more than 75% of its recent graduates going into hospital medicine careers. The program leaders also believe that with a continually shrinking pool of applicants for all of internal medicine their resident recruitment would be enhanced if they marketed their residency as a dedicated training program for the future hospitalists; cardiologists and outpatient internists need not apply.

The program leaders envision basing the new internal medicine residency curriculum on the SHM Core Competencies in Hospital Medicine and meeting RRC requirements for 33% of the training being outpatient in focus by training the future hospitalists in working to help the emergency department physicians with decision making, opening an outpatient clinic for the first one to two post-discharge follow-up visits, and starting an IMPACT clinic (such as the one started by hospitalists at the Cleveland Clinic) to evaluate preoperative patients.

This new residency program would also promote training in systems approaches, epidemiology, quality improvement, information technology, team building, leadership, and management.

The hope is that by narrowing the focus, this residency can attract better applicants, focus the training on a specific type of future internist, and have their graduates viewed by hospitalist employers as very desirable candidates for future hospitalist jobs.

Obviously, this revolutionary approach is a delicate path to walk. Because this is an idea working its way through its home institution, I have agreed to be purposely vague about where this is being investigated for now. Like the executive leadership at Rockford Health System, if the leadership of this hospital and medical staff can be equally visionary, I expect they will be looking for SHM and everyone else to promote this unique internal medicine residency and get the word out.

Mentored Implementation for QI

Not to be left out, SHM is doing its part in creating innovations to move forward hospital medicine’s agenda of change.

SHM has recently obtained two years’ worth of support from The Sanofi-Aventis Group to create and implement a mentored process to develop the hospitalist leaders who will be trained to measure and improve the quality of care that their hospitals deliver—especially in DVT prevention and treatment. Once these skills are learned, we hope that the same precepts can be used for other disease states that hospitalists manage.

This approach is modeled on similar approaches that have been successful in extending the reach of palliative care training. SHM’s idea is to select 10 outstanding hospitalist leaders and train them to do two fundamental things:

1. Use SHM QI tools to measure and improve quality at their institutions; and
2. Be trained to mentor future hospitalist leaders.

SHM would then use these initial 10 mentors to train another 30 hospitalist leaders (three for each initial mentor) in QI and potentially as future mentors.

Using this initial two-year project as a learning guide for process improvement and to develop the first cadre of quality mentors, the next step might be to ask for support from a foundation such as Hartford Foundation or Robert Wood Johnson Foundation—or a governmental agency such as the Agency for Healthcare Quality and Research—for broader funding to expand this initiative to 100 or even 500 sites. The goal would be to create a framework that would develop a hospitalist leader trained to lead the quality initiatives at every hospital in the country.

There are other partnerships that SHM is exploring to make this a reality. Recently SHM senior staff and leadership traveled to Boston to meet with senior leadership at the Institute for Healthcare Improvement (IHI). During those meetings, IHI CEO Don Berwick called hospitalists the “army for quality improvement implementation in our nation’s hospitals.” Ambitious undertakings like SHM’s mentored implementation project will be needed to export the well-known and well-documented knowledge of quality improvement and translate this down to the bedside.

Hospital medicine today is much more potential than reality. The history of American innovation is littered with ideas that failed because of issues with scope, scalability, or poor timing. In an era calling for evidence-based medicine, accountability, measured quality, teamwork, and a renewed emphasis on the patient, there are many stakeholders in healthcare rooting for (and even counting on) hospital medicine to turn promise into performance. We must not let the perfect be the enemy of the good. The status quo is just not good enough, and we will need to be risk takers and adventuresome to achieve great things.

In his book Organizing Genius: The Secrets of Creative Collaboration, Warren Bennis explores the success of such diverse enterprises as the development by Apple of the Macintosh, the engineering mastery at Lockheed Martin’s Skunk Works of the stealth aircraft, the Manhattan Project that developed the nuclear bomb, and Disney’s creation of animated feature films (e.g., “Snow White”) and found that an adventurous spirit was critical element. Adventure was defined as “risk, jeopardy, a daring feat, encountering a hazardous enterprise.”

Hospital medicine is on no less of an adventure. The prize at the end of the journey is better healthcare for our communities. Hospitalists are the soldiers in this battle. Whether you are the general or the foot soldier, we must all help prevail. SHM will be there to do its part. TH

Dr. Wellikson has been CEO of SHM since 2000.

Spring and summer are the seasons of hope and promise. A time when seedlings turn into harvests, when every baseball team has hope, when things seem fresh and new. Hospital medicine is a specialty of hope and promise, of better things in the future. Hospitalists have the potential to change the course of medical care in the acute setting. Right now there are glimmers of this promise turning into realities.

We are seeing centers of experimentation as healthcare institutions and their visionary leaders use their ideas and energies to pilot test what may eventually be common changes throughout the country.

First Hospital Medicine Unit Being Built

In Rockford, Ill., the first Hospital Medicine Unit in Illinois—and possibly the country—is under construction. With a heritage as one of the first hospital medicine groups in Illinois, Rockford Health System is no stranger to innovation. They are currently framing the physical plant for a 17-bed hospital medicine unit and putting this right next to an ICU.

This unit will incorporate many of the accoutrements central to the design elements from the Hospital of the Future project that SHM is involved in with JCAHO and the Robert Wood Johnson Foundation. This plays into the SHM vision of the hospital of the future as patient centered, built on measurable quality, and delivered by teams.

All the rooms will be private with a healing environment incorporating the values of aesthetics, including restful light and sound. The design is set to promote communication and contact between the healthcare team and the patients and their families.

This unit will enhance efficiencies and quality care by concentrating hospitalists’ patients on one dedicated unit. The intent is to use this physical environment to create and reinforce a stronger team approach among hospitalists, nurses, pharmacists, therapists, and the rest of the healthcare team. There will be an opportunity to pilot new technology and treatment protocols to find out what works and what doesn’t. There will also be an opportunity to increase patient and family satisfaction.

As Lars Armainsson, chairman of the Rockford Hospital Medicine Department, says, “We’re pioneers in the way that we are transforming the way care is delivered, using the most advanced and sophisticated practice model to accommodate the 21st century.”

SHM, the rest of hospital medicine, and the C-suite of other hospitals will be waiting to hear how the Rockford Hospital Medicine Unit plays out. We hope the lessons learned there will soon provide a beacon of clarity for others to follow.

Three-Year Hospital Medicine Residency Track

The crisis in internal medicine residency training and the poor results in the recent intern match have at least one internal medicine residency program taking extreme measures to redesign and remarket its program to today’s medical students.

A residency program director in the West has contacted SHM about the feasibility of creating the first internal medicine residency to train only future hospitalists. This program has experienced more than 75% of its recent graduates going into hospital medicine careers. The program leaders also believe that with a continually shrinking pool of applicants for all of internal medicine their resident recruitment would be enhanced if they marketed their residency as a dedicated training program for the future hospitalists; cardiologists and outpatient internists need not apply.

The program leaders envision basing the new internal medicine residency curriculum on the SHM Core Competencies in Hospital Medicine and meeting RRC requirements for 33% of the training being outpatient in focus by training the future hospitalists in working to help the emergency department physicians with decision making, opening an outpatient clinic for the first one to two post-discharge follow-up visits, and starting an IMPACT clinic (such as the one started by hospitalists at the Cleveland Clinic) to evaluate preoperative patients.

This new residency program would also promote training in systems approaches, epidemiology, quality improvement, information technology, team building, leadership, and management.

The hope is that by narrowing the focus, this residency can attract better applicants, focus the training on a specific type of future internist, and have their graduates viewed by hospitalist employers as very desirable candidates for future hospitalist jobs.

Obviously, this revolutionary approach is a delicate path to walk. Because this is an idea working its way through its home institution, I have agreed to be purposely vague about where this is being investigated for now. Like the executive leadership at Rockford Health System, if the leadership of this hospital and medical staff can be equally visionary, I expect they will be looking for SHM and everyone else to promote this unique internal medicine residency and get the word out.

Mentored Implementation for QI

Not to be left out, SHM is doing its part in creating innovations to move forward hospital medicine’s agenda of change.

SHM has recently obtained two years’ worth of support from The Sanofi-Aventis Group to create and implement a mentored process to develop the hospitalist leaders who will be trained to measure and improve the quality of care that their hospitals deliver—especially in DVT prevention and treatment. Once these skills are learned, we hope that the same precepts can be used for other disease states that hospitalists manage.

This approach is modeled on similar approaches that have been successful in extending the reach of palliative care training. SHM’s idea is to select 10 outstanding hospitalist leaders and train them to do two fundamental things:

1. Use SHM QI tools to measure and improve quality at their institutions; and
2. Be trained to mentor future hospitalist leaders.

SHM would then use these initial 10 mentors to train another 30 hospitalist leaders (three for each initial mentor) in QI and potentially as future mentors.

Using this initial two-year project as a learning guide for process improvement and to develop the first cadre of quality mentors, the next step might be to ask for support from a foundation such as Hartford Foundation or Robert Wood Johnson Foundation—or a governmental agency such as the Agency for Healthcare Quality and Research—for broader funding to expand this initiative to 100 or even 500 sites. The goal would be to create a framework that would develop a hospitalist leader trained to lead the quality initiatives at every hospital in the country.

There are other partnerships that SHM is exploring to make this a reality. Recently SHM senior staff and leadership traveled to Boston to meet with senior leadership at the Institute for Healthcare Improvement (IHI). During those meetings, IHI CEO Don Berwick called hospitalists the “army for quality improvement implementation in our nation’s hospitals.” Ambitious undertakings like SHM’s mentored implementation project will be needed to export the well-known and well-documented knowledge of quality improvement and translate this down to the bedside.

Hospital medicine today is much more potential than reality. The history of American innovation is littered with ideas that failed because of issues with scope, scalability, or poor timing. In an era calling for evidence-based medicine, accountability, measured quality, teamwork, and a renewed emphasis on the patient, there are many stakeholders in healthcare rooting for (and even counting on) hospital medicine to turn promise into performance. We must not let the perfect be the enemy of the good. The status quo is just not good enough, and we will need to be risk takers and adventuresome to achieve great things.

In his book Organizing Genius: The Secrets of Creative Collaboration, Warren Bennis explores the success of such diverse enterprises as the development by Apple of the Macintosh, the engineering mastery at Lockheed Martin’s Skunk Works of the stealth aircraft, the Manhattan Project that developed the nuclear bomb, and Disney’s creation of animated feature films (e.g., “Snow White”) and found that an adventurous spirit was critical element. Adventure was defined as “risk, jeopardy, a daring feat, encountering a hazardous enterprise.”

Hospital medicine is on no less of an adventure. The prize at the end of the journey is better healthcare for our communities. Hospitalists are the soldiers in this battle. Whether you are the general or the foot soldier, we must all help prevail. SHM will be there to do its part. TH

Dr. Wellikson has been CEO of SHM since 2000.

Some estimates indicate there are upward of 15,000 hospitalists practicing hospital medicine. And it seems that at any one time 8,000 of them are looking for their first or next job. Most hospital medicine groups are starting up or growing. And with the mobility of our specialty, retention has become as important as recruitment.

SHM has a number of initiatives that can help hospitalists and hospitalist employers sort all this out.

If you are looking for a new opportunity in hospital medicine, your first stop has probably been the extensive recruitment ad pages (“SHM Career Center”) in The Hospitalist. And now SHM has created a unique online “SHM Career Center” that we will match up against CareerBuilder.com or Monster.com for functionality and ease of use. We hope to grow this to be the most extensive collection of hospitalist opportunities anywhere.

Any visitor to the SHM Web site (www.hospitalmedicine.org/careercenter) can view all of the career opportunities and sort through them by setting (academic or community hospital), employer type (hospital or hospitalist group or multispecialty group), and geographic location. You can also look for pediatric or adult-patient hospitalist positions or for full-time or part-time jobs—or even nocturnists.

What’s more, SHM members really can customize their job search at the online “SHM Career Center.” If you belong to SHM you can have jobs e-mailed right to your inbox. You can set your own search parameters, such as “Show me all the jobs where the employer is a hospitalist-only group in Maryland and Pennsylvania.” You can also post a blind resume for potential employers to review and contact you confidentially. Every day just turn on your computer, fire up your e-mail, and there will be jobs waiting for you to investigate.

SHM will also have tips on how to write a resume, how to interview, what you should look for in work hours and compensation, and just about everything you need to find your first job or your next job.

For those hospital medicine groups looking for their next hospitalist, the online “SHM Career Center” will most likely give you the most selected group of hospitalists looking for your job ad. SHM has tried to be the best source to meet the hospitalists’ needs and this is just the next idea we came up with.

Come and give the online “SHM Career Center” a look-see and let us know what you think. Better yet: Become an SHM member and have the jobs come to you.

Career Satisfaction

Once you get that right job, SHM wants to help you make a career in hospital medicine. Every new specialty runs the risk of creating exceptional demands in their early years until everyone figures out just the right formula. Right now SHM has convened a Career Satisfaction Task Force that is conducting research, hosting focus groups, and developing guidelines and parameters to help hospitalists understand what elements lead to the best chance of a satisfying career.

Emergency department physicians went through this in the early days when they went from working 24 shifts a month to 14 to 16 shifts. Pilots developed mandatory work hour restriction to avoid sleepy or stressful situations. We know it feels uncomfortable sometimes to be the pioneer element while things are still in flux. But help is on the way.

The good news is that employers are just as concerned about your job satisfaction and preventing burnout as you are (although it may not always seem that way). Many hospital medicine groups and hospitals are realizing that once you find the right hospitalists it takes commitment to retain them and nourish their career. It is expensive and disruptive to have a high turnover in a hospital medicine group. That is why SHM anticipates that many hospitals and hospital medicine groups will want to adopt the conditions that can lead to stability.

In addition to the work of the Career Satisfaction Task Force, the recently released data from the 2005-2006 Hospitalist Compensation and Productivity Survey will be another key element in creating the proper balance of work and pay for hospitalists. This year we had the largest response of hospitalist leaders (and an 85% increase from pediatric hospitalists alone), and SHM believes the current data are the most reliable in defining hospital medicine.

SHM members have access to the complete survey information—either online, on a CD, or in print. Make sure your hospital and your group uses this compensation and productivity gold standard as you make your staffing and compensation decisions.

Young Physicians Have Needs, Too

Obviously most of this is also applicable to physicians in training and in early career, but SHM wants to play an important role in the decision to become a hospitalist and wants to provide the young hospitalist with the skills to succeed. SHM is involved in efforts to redesign internal medicine residencies to make them more applicable to the way medicine is practiced in the 21st century. In the new schema there will be a core of internal medicine that everyone must be competent in. Then there will be an opportunity for individuals to elect to take the latter part of their residency with an emphasis on hospital medicine, a subspecialty, or ambulatory skills. SHM plans to use the recently published SHM Core Competencies in Hospital Medicine as a basis for our efforts in this redesign.

SHM is also developing materials to help medical students and residents understand just what a career in hospital medicine entails. We feel the more the young physicians understand the total picture of hospital medicine the more this will be a sought-after career choice. Hospitalists will have a role in direct patient care, leading change at their hospitals, improving quality, and still be able to have a full life outside of medicine.

The hospital medicine marketplace is still being defined. There is still significant room for growth and mobility. It will be a while before stability settles in. In fact there really is no status quo to use as a benchmark. In all this turbulence, SHM continues to create the tools and resources to help you find a sustainable career in hospital medicine—or to at least help you find your next job. TH

Dr. Wellikson has been CEO of SHM since 2000.

Some estimates indicate there are upward of 15,000 hospitalists practicing hospital medicine. And it seems that at any one time 8,000 of them are looking for their first or next job. Most hospital medicine groups are starting up or growing. And with the mobility of our specialty, retention has become as important as recruitment.

SHM has a number of initiatives that can help hospitalists and hospitalist employers sort all this out.

If you are looking for a new opportunity in hospital medicine, your first stop has probably been the extensive recruitment ad pages (“SHM Career Center”) in The Hospitalist. And now SHM has created a unique online “SHM Career Center” that we will match up against CareerBuilder.com or Monster.com for functionality and ease of use. We hope to grow this to be the most extensive collection of hospitalist opportunities anywhere.

Any visitor to the SHM Web site (www.hospitalmedicine.org/careercenter) can view all of the career opportunities and sort through them by setting (academic or community hospital), employer type (hospital or hospitalist group or multispecialty group), and geographic location. You can also look for pediatric or adult-patient hospitalist positions or for full-time or part-time jobs—or even nocturnists.

What’s more, SHM members really can customize their job search at the online “SHM Career Center.” If you belong to SHM you can have jobs e-mailed right to your inbox. You can set your own search parameters, such as “Show me all the jobs where the employer is a hospitalist-only group in Maryland and Pennsylvania.” You can also post a blind resume for potential employers to review and contact you confidentially. Every day just turn on your computer, fire up your e-mail, and there will be jobs waiting for you to investigate.

SHM will also have tips on how to write a resume, how to interview, what you should look for in work hours and compensation, and just about everything you need to find your first job or your next job.

For those hospital medicine groups looking for their next hospitalist, the online “SHM Career Center” will most likely give you the most selected group of hospitalists looking for your job ad. SHM has tried to be the best source to meet the hospitalists’ needs and this is just the next idea we came up with.

Come and give the online “SHM Career Center” a look-see and let us know what you think. Better yet: Become an SHM member and have the jobs come to you.

Career Satisfaction

Once you get that right job, SHM wants to help you make a career in hospital medicine. Every new specialty runs the risk of creating exceptional demands in their early years until everyone figures out just the right formula. Right now SHM has convened a Career Satisfaction Task Force that is conducting research, hosting focus groups, and developing guidelines and parameters to help hospitalists understand what elements lead to the best chance of a satisfying career.

Emergency department physicians went through this in the early days when they went from working 24 shifts a month to 14 to 16 shifts. Pilots developed mandatory work hour restriction to avoid sleepy or stressful situations. We know it feels uncomfortable sometimes to be the pioneer element while things are still in flux. But help is on the way.

The good news is that employers are just as concerned about your job satisfaction and preventing burnout as you are (although it may not always seem that way). Many hospital medicine groups and hospitals are realizing that once you find the right hospitalists it takes commitment to retain them and nourish their career. It is expensive and disruptive to have a high turnover in a hospital medicine group. That is why SHM anticipates that many hospitals and hospital medicine groups will want to adopt the conditions that can lead to stability.

In addition to the work of the Career Satisfaction Task Force, the recently released data from the 2005-2006 Hospitalist Compensation and Productivity Survey will be another key element in creating the proper balance of work and pay for hospitalists. This year we had the largest response of hospitalist leaders (and an 85% increase from pediatric hospitalists alone), and SHM believes the current data are the most reliable in defining hospital medicine.

SHM members have access to the complete survey information—either online, on a CD, or in print. Make sure your hospital and your group uses this compensation and productivity gold standard as you make your staffing and compensation decisions.

Young Physicians Have Needs, Too

Obviously most of this is also applicable to physicians in training and in early career, but SHM wants to play an important role in the decision to become a hospitalist and wants to provide the young hospitalist with the skills to succeed. SHM is involved in efforts to redesign internal medicine residencies to make them more applicable to the way medicine is practiced in the 21st century. In the new schema there will be a core of internal medicine that everyone must be competent in. Then there will be an opportunity for individuals to elect to take the latter part of their residency with an emphasis on hospital medicine, a subspecialty, or ambulatory skills. SHM plans to use the recently published SHM Core Competencies in Hospital Medicine as a basis for our efforts in this redesign.

SHM is also developing materials to help medical students and residents understand just what a career in hospital medicine entails. We feel the more the young physicians understand the total picture of hospital medicine the more this will be a sought-after career choice. Hospitalists will have a role in direct patient care, leading change at their hospitals, improving quality, and still be able to have a full life outside of medicine.

The hospital medicine marketplace is still being defined. There is still significant room for growth and mobility. It will be a while before stability settles in. In fact there really is no status quo to use as a benchmark. In all this turbulence, SHM continues to create the tools and resources to help you find a sustainable career in hospital medicine—or to at least help you find your next job. TH

Dr. Wellikson has been CEO of SHM since 2000.

Some estimates indicate there are upward of 15,000 hospitalists practicing hospital medicine. And it seems that at any one time 8,000 of them are looking for their first or next job. Most hospital medicine groups are starting up or growing. And with the mobility of our specialty, retention has become as important as recruitment.

SHM has a number of initiatives that can help hospitalists and hospitalist employers sort all this out.

If you are looking for a new opportunity in hospital medicine, your first stop has probably been the extensive recruitment ad pages (“SHM Career Center”) in The Hospitalist. And now SHM has created a unique online “SHM Career Center” that we will match up against CareerBuilder.com or Monster.com for functionality and ease of use. We hope to grow this to be the most extensive collection of hospitalist opportunities anywhere.

Any visitor to the SHM Web site (www.hospitalmedicine.org/careercenter) can view all of the career opportunities and sort through them by setting (academic or community hospital), employer type (hospital or hospitalist group or multispecialty group), and geographic location. You can also look for pediatric or adult-patient hospitalist positions or for full-time or part-time jobs—or even nocturnists.

What’s more, SHM members really can customize their job search at the online “SHM Career Center.” If you belong to SHM you can have jobs e-mailed right to your inbox. You can set your own search parameters, such as “Show me all the jobs where the employer is a hospitalist-only group in Maryland and Pennsylvania.” You can also post a blind resume for potential employers to review and contact you confidentially. Every day just turn on your computer, fire up your e-mail, and there will be jobs waiting for you to investigate.

SHM will also have tips on how to write a resume, how to interview, what you should look for in work hours and compensation, and just about everything you need to find your first job or your next job.

For those hospital medicine groups looking for their next hospitalist, the online “SHM Career Center” will most likely give you the most selected group of hospitalists looking for your job ad. SHM has tried to be the best source to meet the hospitalists’ needs and this is just the next idea we came up with.

Come and give the online “SHM Career Center” a look-see and let us know what you think. Better yet: Become an SHM member and have the jobs come to you.

Career Satisfaction

Once you get that right job, SHM wants to help you make a career in hospital medicine. Every new specialty runs the risk of creating exceptional demands in their early years until everyone figures out just the right formula. Right now SHM has convened a Career Satisfaction Task Force that is conducting research, hosting focus groups, and developing guidelines and parameters to help hospitalists understand what elements lead to the best chance of a satisfying career.

Emergency department physicians went through this in the early days when they went from working 24 shifts a month to 14 to 16 shifts. Pilots developed mandatory work hour restriction to avoid sleepy or stressful situations. We know it feels uncomfortable sometimes to be the pioneer element while things are still in flux. But help is on the way.

The good news is that employers are just as concerned about your job satisfaction and preventing burnout as you are (although it may not always seem that way). Many hospital medicine groups and hospitals are realizing that once you find the right hospitalists it takes commitment to retain them and nourish their career. It is expensive and disruptive to have a high turnover in a hospital medicine group. That is why SHM anticipates that many hospitals and hospital medicine groups will want to adopt the conditions that can lead to stability.

In addition to the work of the Career Satisfaction Task Force, the recently released data from the 2005-2006 Hospitalist Compensation and Productivity Survey will be another key element in creating the proper balance of work and pay for hospitalists. This year we had the largest response of hospitalist leaders (and an 85% increase from pediatric hospitalists alone), and SHM believes the current data are the most reliable in defining hospital medicine.

SHM members have access to the complete survey information—either online, on a CD, or in print. Make sure your hospital and your group uses this compensation and productivity gold standard as you make your staffing and compensation decisions.

Young Physicians Have Needs, Too

Obviously most of this is also applicable to physicians in training and in early career, but SHM wants to play an important role in the decision to become a hospitalist and wants to provide the young hospitalist with the skills to succeed. SHM is involved in efforts to redesign internal medicine residencies to make them more applicable to the way medicine is practiced in the 21st century. In the new schema there will be a core of internal medicine that everyone must be competent in. Then there will be an opportunity for individuals to elect to take the latter part of their residency with an emphasis on hospital medicine, a subspecialty, or ambulatory skills. SHM plans to use the recently published SHM Core Competencies in Hospital Medicine as a basis for our efforts in this redesign.

SHM is also developing materials to help medical students and residents understand just what a career in hospital medicine entails. We feel the more the young physicians understand the total picture of hospital medicine the more this will be a sought-after career choice. Hospitalists will have a role in direct patient care, leading change at their hospitals, improving quality, and still be able to have a full life outside of medicine.

The hospital medicine marketplace is still being defined. There is still significant room for growth and mobility. It will be a while before stability settles in. In fact there really is no status quo to use as a benchmark. In all this turbulence, SHM continues to create the tools and resources to help you find a sustainable career in hospital medicine—or to at least help you find your next job. TH

Dr. Wellikson has been CEO of SHM since 2000.

Have you ever looked out your window and wondered, “When did that tree get planted?” Or wonder when you pass a new building that wasn’t there last week, “When did they build that?” Or remember a time when everyone didn’t have an iPod or a Treo Smartphone or Blackberry?

Well, hospital medicine and SHM are rapidly becoming the iPods of healthcare. We are still catching some by surprise. Others think we are everywhere, touching everything, and sometimes leaving them asking the universal question from Butch Cassidy and the Sundance Kids, “Who are those guys?”

Most of you know that while the adoption of hospital medicine and its meteoric rise seems at times a force of nature on a random and indeterminate course, the all too true reality is that many of the “sudden” advances by SHM have been many years in the planning. More than that, they have required key partnerships and significant behind the scenes activity.

It is very much akin to the sudden stardom of veteran performers who have been honing their craft under a smaller spotlight waiting for their time to come. The time for hospital medicine is now.

This is all the more important because hospital medicine has been getting by as a growth story for a while now and it is time to add the substance that will propel our specialty forward as a permanent part of the medical landscape and a key partner in improvement strategies for hospitals and our patients’ care.

Hospital medicine has its own repository now for our contributions to science and the formulation of the hospital of the future in the Journal of Hospital Medicine. The inaugural issue has met with accolades and acceptance. The second issue is on the way and soon it will seem like there has always been a JHM.

The first issue of JHM was all the more important and noteworthy because it was accompanied by a supplement: The Core Competencies in Hospital Medicine. Years in the making, this thoughtful document put SHM’s nickel down and said “Here is what makes hospital medicine unique: an evolving specialty, emanating from our roots in internal medicine, family practice, and pediatrics, but with a relevance to the practice of medicine in our nation’s hospitals in the 21st century.”

Fully accepting the hospitalists’ role in building teams, improving quality, driving hospital efficiencies, and promoting effective care, we hope the Competencies will be part of our road map as we participate in such important but disparate efforts as redesigning internal medicine training, developing a unique credential for hospitalists, and planning the hospital of the future.

These efforts, like JHM or The Core Competencies just a few years ago, are concepts today that will form the reality in the near term. As they develop I will use this space to bring you new developments and prepare all of us for our active roles in defining, participating in, and implementing the new future.

Recognition of Hospitalists

For several years SHM has been talking with the thought leaders in internal medicine including American Board of Internal Medicine (ABIM), American College of Physicians (ACP), Alliance for Academic Internal Medicine (AAIM), and others about not only the growth in size of hospital medicine, but the unique practice of hospitalists that defines us as related and as distinct from the rest of internal medicine as cardiology or critical care.

We started with internal medicine because more than 85% of hospitalists are trained as internists. But our strategy is to soon follow on with discussions with the American Board of Family Practice (ABFP), the American Board of Pediatrics (ABP), osteopathic certification organizations, and others who oversee any part of credentialing hospitalists.

The ABIM with the support of the ACP, the AAIM, SHM, and others has embarked on a process to use the Maintenance of Certification (MOC) to create a unique recognition for hospital medicine without requiring additional formal training beyond current residencies. The plan for now is that all graduates of an internal medicine residency would take the same initial certification, but that after entering practice and sometime within the first 10 years of practice, hospitalists could use the elements of the MOC process (e.g., self assessment, a quality improvement process, and a secure test—all specific to hospital medicine practice) to create a recognition of them as hospitalists. Presently, the ABIM has formed a Hospital Medicine Task Force to develop the details that will make this rigorous and meaningful to the key stakeholders (e.g., hospitals, patients, hospitalist employers, referring physicians, and hospitalists).

Getting this far was not in any way a slam dunk or a rubber stamp. SHM didn’t just send in a postcard asking for a credential for hospitalists and ABIM said, “Fine.” This has taken several years of reasoned conversations, meetings to clarify our position, and opportunities to understand the broader aspects of the emergence of hospital medicine’s effect on the rest of medicine. More recently it has taken the courageous leadership and vision of the ABIM, the ACP, the AAIM, and others to meet their missions of promoting quality of care for our patients.

Work still needs to be done and the devil is always in the details. But the current direction is forward, and that is surely welcome.

Working to Improve Quality

There has been much heat and fury around quality—defining it, measuring it, even possibly paying for it, instead of just paying for units of work whether they are any good or not. For many years the role of the professional medical society in the quality arena was to pull together the smartest people in their specialty, latch on to the diseases they knew the most about, define quality, write guidelines, issue a white paper, and declare victory.

From its beginning SHM has taken a different tactic. We believe many smart people have already defined the best quality for DVT or diabetes or CHF, but the remaining gaps have been in implementation strategies to export all these great ideas to 5,000 hospitals and the millions of patients who occupy them.

With this in mind SHM has sought funding in the diseases defined in our Core Competencies such as DVT, diabetes, CHF, and others, and we have looked for ways to provide hospitalists with key tools as well as looking for implementation strategies (e.g., mentorship, training courses in leadership and the quality improvement process, demonstration projects) to make a measurable difference. And as hospitalists begin to become change agents at their hospitals, we hope to use our meetings and our publications to report your successes and the barriers to success.

Once again SHM will not be able to do much on our own. Therefore, our strategy has been to involve very early on the leaders in nursing, pharmacy, case management, and relevant specialties of medicine. In fashioning a strategy for glycemic control in the hospital, for example, SHM works with the American Association of Clinical Endocrinologists, the American Diabetic Association, and others. Once again as early vague ideas take shape and become real programs, it seems as if they have appeared fully formed in short order. But SHM has been working on many of these for years, and we expect that we will be in the quality improvement implementation realm for many years to come. We are just getting started.

But here is where you are so important. At its best SHM is not much more than an aggregator of good ideas and the developer of strategies. You make it happen. We can design the Ferrari and maybe even provide a shopping list for parts and an instruction manual for assembling and operating. But you have to assemble the car and take it out on the road. It is our nation’s hospitalists, along with key partners and team members at their local institutions, who will provide the coefficients for change and the impetus for improvement.

Once you do this, SHM will have a role to praise, reward, and even prod you and to shine a bright light on all your work so others will be encouraged to take their shot and make great things happen.

SHM, like the hospitalists who form us, is a paradox. On first glance, we are patient and thoughtful with a longer look at the future and all the changes that will be required. At the same time we want to take our innovations and put them in place this week. We think the fearlessness of youth and open-box thinking is just what we need in healthcare today. We rely on our partners to temper our rush to action with their experience and wisdom and additional perspectives. The times require change. Together we can make sure it is a change for the better. TH

Dr. Wellikson has been CEO of SHM since 2000.

Have you ever looked out your window and wondered, “When did that tree get planted?” Or wonder when you pass a new building that wasn’t there last week, “When did they build that?” Or remember a time when everyone didn’t have an iPod or a Treo Smartphone or Blackberry?

Well, hospital medicine and SHM are rapidly becoming the iPods of healthcare. We are still catching some by surprise. Others think we are everywhere, touching everything, and sometimes leaving them asking the universal question from Butch Cassidy and the Sundance Kids, “Who are those guys?”

Most of you know that while the adoption of hospital medicine and its meteoric rise seems at times a force of nature on a random and indeterminate course, the all too true reality is that many of the “sudden” advances by SHM have been many years in the planning. More than that, they have required key partnerships and significant behind the scenes activity.

It is very much akin to the sudden stardom of veteran performers who have been honing their craft under a smaller spotlight waiting for their time to come. The time for hospital medicine is now.

This is all the more important because hospital medicine has been getting by as a growth story for a while now and it is time to add the substance that will propel our specialty forward as a permanent part of the medical landscape and a key partner in improvement strategies for hospitals and our patients’ care.

Hospital medicine has its own repository now for our contributions to science and the formulation of the hospital of the future in the Journal of Hospital Medicine. The inaugural issue has met with accolades and acceptance. The second issue is on the way and soon it will seem like there has always been a JHM.

The first issue of JHM was all the more important and noteworthy because it was accompanied by a supplement: The Core Competencies in Hospital Medicine. Years in the making, this thoughtful document put SHM’s nickel down and said “Here is what makes hospital medicine unique: an evolving specialty, emanating from our roots in internal medicine, family practice, and pediatrics, but with a relevance to the practice of medicine in our nation’s hospitals in the 21st century.”

Fully accepting the hospitalists’ role in building teams, improving quality, driving hospital efficiencies, and promoting effective care, we hope the Competencies will be part of our road map as we participate in such important but disparate efforts as redesigning internal medicine training, developing a unique credential for hospitalists, and planning the hospital of the future.

These efforts, like JHM or The Core Competencies just a few years ago, are concepts today that will form the reality in the near term. As they develop I will use this space to bring you new developments and prepare all of us for our active roles in defining, participating in, and implementing the new future.

Recognition of Hospitalists

For several years SHM has been talking with the thought leaders in internal medicine including American Board of Internal Medicine (ABIM), American College of Physicians (ACP), Alliance for Academic Internal Medicine (AAIM), and others about not only the growth in size of hospital medicine, but the unique practice of hospitalists that defines us as related and as distinct from the rest of internal medicine as cardiology or critical care.

We started with internal medicine because more than 85% of hospitalists are trained as internists. But our strategy is to soon follow on with discussions with the American Board of Family Practice (ABFP), the American Board of Pediatrics (ABP), osteopathic certification organizations, and others who oversee any part of credentialing hospitalists.

The ABIM with the support of the ACP, the AAIM, SHM, and others has embarked on a process to use the Maintenance of Certification (MOC) to create a unique recognition for hospital medicine without requiring additional formal training beyond current residencies. The plan for now is that all graduates of an internal medicine residency would take the same initial certification, but that after entering practice and sometime within the first 10 years of practice, hospitalists could use the elements of the MOC process (e.g., self assessment, a quality improvement process, and a secure test—all specific to hospital medicine practice) to create a recognition of them as hospitalists. Presently, the ABIM has formed a Hospital Medicine Task Force to develop the details that will make this rigorous and meaningful to the key stakeholders (e.g., hospitals, patients, hospitalist employers, referring physicians, and hospitalists).

Getting this far was not in any way a slam dunk or a rubber stamp. SHM didn’t just send in a postcard asking for a credential for hospitalists and ABIM said, “Fine.” This has taken several years of reasoned conversations, meetings to clarify our position, and opportunities to understand the broader aspects of the emergence of hospital medicine’s effect on the rest of medicine. More recently it has taken the courageous leadership and vision of the ABIM, the ACP, the AAIM, and others to meet their missions of promoting quality of care for our patients.

Work still needs to be done and the devil is always in the details. But the current direction is forward, and that is surely welcome.

Working to Improve Quality

There has been much heat and fury around quality—defining it, measuring it, even possibly paying for it, instead of just paying for units of work whether they are any good or not. For many years the role of the professional medical society in the quality arena was to pull together the smartest people in their specialty, latch on to the diseases they knew the most about, define quality, write guidelines, issue a white paper, and declare victory.

From its beginning SHM has taken a different tactic. We believe many smart people have already defined the best quality for DVT or diabetes or CHF, but the remaining gaps have been in implementation strategies to export all these great ideas to 5,000 hospitals and the millions of patients who occupy them.

With this in mind SHM has sought funding in the diseases defined in our Core Competencies such as DVT, diabetes, CHF, and others, and we have looked for ways to provide hospitalists with key tools as well as looking for implementation strategies (e.g., mentorship, training courses in leadership and the quality improvement process, demonstration projects) to make a measurable difference. And as hospitalists begin to become change agents at their hospitals, we hope to use our meetings and our publications to report your successes and the barriers to success.

Once again SHM will not be able to do much on our own. Therefore, our strategy has been to involve very early on the leaders in nursing, pharmacy, case management, and relevant specialties of medicine. In fashioning a strategy for glycemic control in the hospital, for example, SHM works with the American Association of Clinical Endocrinologists, the American Diabetic Association, and others. Once again as early vague ideas take shape and become real programs, it seems as if they have appeared fully formed in short order. But SHM has been working on many of these for years, and we expect that we will be in the quality improvement implementation realm for many years to come. We are just getting started.

But here is where you are so important. At its best SHM is not much more than an aggregator of good ideas and the developer of strategies. You make it happen. We can design the Ferrari and maybe even provide a shopping list for parts and an instruction manual for assembling and operating. But you have to assemble the car and take it out on the road. It is our nation’s hospitalists, along with key partners and team members at their local institutions, who will provide the coefficients for change and the impetus for improvement.

Once you do this, SHM will have a role to praise, reward, and even prod you and to shine a bright light on all your work so others will be encouraged to take their shot and make great things happen.

SHM, like the hospitalists who form us, is a paradox. On first glance, we are patient and thoughtful with a longer look at the future and all the changes that will be required. At the same time we want to take our innovations and put them in place this week. We think the fearlessness of youth and open-box thinking is just what we need in healthcare today. We rely on our partners to temper our rush to action with their experience and wisdom and additional perspectives. The times require change. Together we can make sure it is a change for the better. TH

Dr. Wellikson has been CEO of SHM since 2000.

Have you ever looked out your window and wondered, “When did that tree get planted?” Or wonder when you pass a new building that wasn’t there last week, “When did they build that?” Or remember a time when everyone didn’t have an iPod or a Treo Smartphone or Blackberry?

Well, hospital medicine and SHM are rapidly becoming the iPods of healthcare. We are still catching some by surprise. Others think we are everywhere, touching everything, and sometimes leaving them asking the universal question from Butch Cassidy and the Sundance Kids, “Who are those guys?”

Most of you know that while the adoption of hospital medicine and its meteoric rise seems at times a force of nature on a random and indeterminate course, the all too true reality is that many of the “sudden” advances by SHM have been many years in the planning. More than that, they have required key partnerships and significant behind the scenes activity.

It is very much akin to the sudden stardom of veteran performers who have been honing their craft under a smaller spotlight waiting for their time to come. The time for hospital medicine is now.

This is all the more important because hospital medicine has been getting by as a growth story for a while now and it is time to add the substance that will propel our specialty forward as a permanent part of the medical landscape and a key partner in improvement strategies for hospitals and our patients’ care.

Hospital medicine has its own repository now for our contributions to science and the formulation of the hospital of the future in the Journal of Hospital Medicine. The inaugural issue has met with accolades and acceptance. The second issue is on the way and soon it will seem like there has always been a JHM.

The first issue of JHM was all the more important and noteworthy because it was accompanied by a supplement: The Core Competencies in Hospital Medicine. Years in the making, this thoughtful document put SHM’s nickel down and said “Here is what makes hospital medicine unique: an evolving specialty, emanating from our roots in internal medicine, family practice, and pediatrics, but with a relevance to the practice of medicine in our nation’s hospitals in the 21st century.”

Fully accepting the hospitalists’ role in building teams, improving quality, driving hospital efficiencies, and promoting effective care, we hope the Competencies will be part of our road map as we participate in such important but disparate efforts as redesigning internal medicine training, developing a unique credential for hospitalists, and planning the hospital of the future.

These efforts, like JHM or The Core Competencies just a few years ago, are concepts today that will form the reality in the near term. As they develop I will use this space to bring you new developments and prepare all of us for our active roles in defining, participating in, and implementing the new future.

Recognition of Hospitalists

For several years SHM has been talking with the thought leaders in internal medicine including American Board of Internal Medicine (ABIM), American College of Physicians (ACP), Alliance for Academic Internal Medicine (AAIM), and others about not only the growth in size of hospital medicine, but the unique practice of hospitalists that defines us as related and as distinct from the rest of internal medicine as cardiology or critical care.

We started with internal medicine because more than 85% of hospitalists are trained as internists. But our strategy is to soon follow on with discussions with the American Board of Family Practice (ABFP), the American Board of Pediatrics (ABP), osteopathic certification organizations, and others who oversee any part of credentialing hospitalists.

The ABIM with the support of the ACP, the AAIM, SHM, and others has embarked on a process to use the Maintenance of Certification (MOC) to create a unique recognition for hospital medicine without requiring additional formal training beyond current residencies. The plan for now is that all graduates of an internal medicine residency would take the same initial certification, but that after entering practice and sometime within the first 10 years of practice, hospitalists could use the elements of the MOC process (e.g., self assessment, a quality improvement process, and a secure test—all specific to hospital medicine practice) to create a recognition of them as hospitalists. Presently, the ABIM has formed a Hospital Medicine Task Force to develop the details that will make this rigorous and meaningful to the key stakeholders (e.g., hospitals, patients, hospitalist employers, referring physicians, and hospitalists).

Getting this far was not in any way a slam dunk or a rubber stamp. SHM didn’t just send in a postcard asking for a credential for hospitalists and ABIM said, “Fine.” This has taken several years of reasoned conversations, meetings to clarify our position, and opportunities to understand the broader aspects of the emergence of hospital medicine’s effect on the rest of medicine. More recently it has taken the courageous leadership and vision of the ABIM, the ACP, the AAIM, and others to meet their missions of promoting quality of care for our patients.

Work still needs to be done and the devil is always in the details. But the current direction is forward, and that is surely welcome.

Working to Improve Quality

There has been much heat and fury around quality—defining it, measuring it, even possibly paying for it, instead of just paying for units of work whether they are any good or not. For many years the role of the professional medical society in the quality arena was to pull together the smartest people in their specialty, latch on to the diseases they knew the most about, define quality, write guidelines, issue a white paper, and declare victory.

From its beginning SHM has taken a different tactic. We believe many smart people have already defined the best quality for DVT or diabetes or CHF, but the remaining gaps have been in implementation strategies to export all these great ideas to 5,000 hospitals and the millions of patients who occupy them.

With this in mind SHM has sought funding in the diseases defined in our Core Competencies such as DVT, diabetes, CHF, and others, and we have looked for ways to provide hospitalists with key tools as well as looking for implementation strategies (e.g., mentorship, training courses in leadership and the quality improvement process, demonstration projects) to make a measurable difference. And as hospitalists begin to become change agents at their hospitals, we hope to use our meetings and our publications to report your successes and the barriers to success.

Once again SHM will not be able to do much on our own. Therefore, our strategy has been to involve very early on the leaders in nursing, pharmacy, case management, and relevant specialties of medicine. In fashioning a strategy for glycemic control in the hospital, for example, SHM works with the American Association of Clinical Endocrinologists, the American Diabetic Association, and others. Once again as early vague ideas take shape and become real programs, it seems as if they have appeared fully formed in short order. But SHM has been working on many of these for years, and we expect that we will be in the quality improvement implementation realm for many years to come. We are just getting started.

But here is where you are so important. At its best SHM is not much more than an aggregator of good ideas and the developer of strategies. You make it happen. We can design the Ferrari and maybe even provide a shopping list for parts and an instruction manual for assembling and operating. But you have to assemble the car and take it out on the road. It is our nation’s hospitalists, along with key partners and team members at their local institutions, who will provide the coefficients for change and the impetus for improvement.

Once you do this, SHM will have a role to praise, reward, and even prod you and to shine a bright light on all your work so others will be encouraged to take their shot and make great things happen.

SHM, like the hospitalists who form us, is a paradox. On first glance, we are patient and thoughtful with a longer look at the future and all the changes that will be required. At the same time we want to take our innovations and put them in place this week. We think the fearlessness of youth and open-box thinking is just what we need in healthcare today. We rely on our partners to temper our rush to action with their experience and wisdom and additional perspectives. The times require change. Together we can make sure it is a change for the better. TH

Dr. Wellikson has been CEO of SHM since 2000.