User login
Look at hospitalists and you’ll find more gray hair, crow’s feet, and accumulated wisdom than you might expect. While many hospitalists are physicians fresh from residency, the average age of a hospitalist is actually 40—in part because some hospitalist are docs who have left office practices in favor of hospital work.
These docs, who we’ll call “mid-career hospitalists,” take diverse paths to this change. Some miss the adrenaline rush of acute care. Others have become weary of the flat reimbursements and high patient volumes needed to maintain office practices today. Whatever their paths, they’re an interesting lot.
The most common scenario by which mid-career hospitalists make a transition is when hospital administrators recruit their own. That’s how Robert Brannon, MD, an Ob/Gyn in private practice since 1968, became a hospitalist at Presbyterian Hospital of Dallas in July 2005. Shrinking reimbursements, the costs of running an office, having to cover night call, and a national request for proposal (RFP) by the hospital precipitated Dr. Brannon’s career move.
He and nine other Ob/Gyns submitted a proposal in response to the RFP; hospital administrators awarded the group, OB on Call, LLP, a contract to start a hospitalist service for a largely indigent population in a hospital with more than 7,000 births annually.
I had already started to phase out the office practice and was working in a Medicaid clinic and an osteoporosis clinic when the hospital decided it had to do better with its indigent patients, particularly the 80 to 90 each month who came in with no prenatal care,” says Dr. Brannon. “The medical staff knew that resident work rules precluded their work off hours, so patient needs indicated that full-time hospitalists were in order.”
Now Dr. Brannon has the camaraderie of working with other hospitalists and neonatologists, delivering many babies, but still eliminating on-call obligations when he’s off duty.
“I’m doing more significant obstetrics work, re-honing my skills, and doing high-risk deliveries,” he says. “I’m doing what I love without the administrative hassles of a private practice.”
Jeffrey Frank, MD, had an even bigger nut to crack when he switched from an office-based practice to start a hospitalist medicine service at Doctors Medical Center (DMC) in San Pablo, Calif. The 45-year-old internist graduated from medical school in 1987 and worked in a four-person medical group in the area he describes as “very industrial, with oil refineries all around and the home base of the Hells Angels.”
—Scott Oxenhandler, MD
Helping to cover hospitalized patients for five HMOs precipitated his career change. “That was a mini-hospitalist assignment, and I felt I could adapt to full-time,” says Dr. Frank.
On DMC’s medical staff for years, Dr. Frank saw the hospital go from first in market share to a distant second after entrepreneurial doctors built a newer hospital north of town. Dr. Frank’s patients were aging and the prospects for improving the office practice were poor. Then there was Dr. Frank’s 800-pound gorilla: Kaiser-Permanente, a giant with 45% market share, with plans geared to younger patients, and physician salaries that his group couldn’t match. DMC continued slowly downhill, with closure a real risk.
In 2004, with his family’s acceptance of the long hours that launching a hospitalist program would take, Dr. Frank initiated discussions with hospital administrators to become its first chief hospitalist. Rather than leaving the office practice and launching a hospitalist service simultaneously, Dr. Frank approached established vendors for help. He chose IPC for its technology infrastructure and electronic medical records, competitive salaries, and the hope of attracting more physicians, whom Dr. Frank eventually recruited locally.
He built the hospitalist patient base by admitting all patients of the two largest medical groups. His entrepreneurial spirit intrigued both IPC and the hospital’s chief financial officer by reducing the average length of stay from 5.3 to 4.0 days, which improved the bottom line. Dr. Frank’s salary then increased by 30%. He says he loves doing acute care again and sees many of his former patients because the medical group has transferred hospital work to the hospitalists.
—Jeffrey Frank, MD
“I was worried about being at the hospital all the time,” says Dr. Frank. “I’m 45 years old, but energetic because there’s lots of work. I can keep up with three of the hospitalists just out of residency. Seeing my old patients also connects me to my old practice.”
Across the country in Hollywood, Fla., Scott Oxenhandler, MD, a geriatrician, couldn’t be happier with his mid-career change from office-based doctor to hospitalist. He left a thriving practice of eight physicians he helped start in 1987 to be chief hospitalist at Hollywood Memorial Regional Hospital (Fla.). Seeing five to eight hospitalized patients every day as their primary physician, he knew the hospital’s inner workings and how to start a hospitalist program—largely for unassigned patients.
“I wanted a free hand practicing acute care medicine, good compensation and benefits, lack of paperwork hassles, and a great schedule,” says Dr. Oxenhandler.
When he started in July 2004 Dr. Oxenhandler had no problem structuring a hospital medicine service that attracted physicians with competitive salaries and schedules to accommodate individual needs. He now has 21 full- and part-time hospitalists. They mostly work 8 a.m. to 5 p.m. with an average daily census of 12 to 15 and several consults. A nocturnist admits patients from 8 p.m. to 8 a.m., and 10 doctors handle 5 p.m. to 8 p.m. short call four times per month.
Overall, the transition for the 48-year-old veteran was surprisingly easy. “I was in the hospital all the time anyway, and the way internal medicine is evolving there have to be connections between inpatient and outpatient doctors,” says Dr. Oxenhandler. As the hospitalist leader he mentors young doctors, knows how to distribute the workload, and loves to share clinical insights.
Other Paths
For a doctor who finished residency at nearly 40, “mid-career change” takes on new meaning. Ron Jacobs, MD, internist, chief medical officer, and co-founder of PrimeDoc Management Services of Asheville, N.C., was a businessman in his 20s, then studied medicine and started an office practice in 1997. That practice—with four internists, a pulmonologist, and a cardiologist—was thriving. But Dr. Jacobs was bored. He missed the hospital’s intensity, was used to visiting six or eight hospitalized patients daily, and decided that seeing 16 or 18 patients without the office practice would suit him. So he co-founded PrimeDoc, which now has 100 hospitalists practicing in 15 programs throughout the Southeast and Mid-Atlantic.
The 49-year-old doctor eases the transition for other mid-lifers, recognizing that avoiding burnout as a hospitalist requires mental and physical preparation.
“The sheer volume of rounding, whether for an [average daily census] of 18 or 13 consults a day is tough,” says Dr. Jacobs. “They’ve got to be solid internists with strong ICU skills. I like diverse teams of older and younger docs. They work well because a team of hospitalists all just out of residency can easily burn out. They need the experience and mentoring of older docs to augment their up-to-date clinical skills.”
Academia is also fertile ground for mid-career changes. A doctor with an office practice and a faculty appointment may someday close the office and return to the hospital he or she loves. (See the profile of Joseph Snitzer, MD: “Sibling Rivalry,” in The Hospitalist, Sept. 2005.) Scott Wilson, MD, of The University of Iowa Hospitals and Clinic, Rapid City, left to start a hospitalist program in 2000 for the 880-bed University Hospital and its 250-bed Veterans Affairs Hospital after many years of teaching in the medical school. Dr. Wilson was tapped to start the hospitalist program because of improvements he had made in educating physicians.
—Ron Jacobs, MD
“Our program has some unique features, particularly our interaction with residents, improving the med school curriculum, and building research into our practice,” says Dr. Wilson.
In 2004 that included a study showing that patients managed by hospitalists had shorter length of stay (LOS) and lower costs than patients managed by non-hospitalists, but had higher costs per day. (Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004 Aug;10 (8):561-568). The schedule’s tough for a non-20-something: call every fourth night, three-week blocks for six months, then six months of research.
Dr. Wilson enjoys the challenge and the $1 million hospital support the program garnered in 2005. “We meet their needs to reduce LOS and improve quality, and we keep growing our program through new tasks such as surgical co-management of orthopedics,” he says.
Recruiting Them
Hospital administrators who want to recruit mid-career physicians as hospitalists need look no further than their own backyards. The internist or family practice doctor who relishes hospital rounds but has to rush back to the office, such as Dr. Oxenhandler, is a prime candidate for hospitalist recruitment. Areas where medical groups have trouble recruiting new doctors because reimbursements are flat (e.g., San Pablo) are also fertile ground for recruiting. Entrepreneurial physicians like Drs. Brannon and Jacobs, who had already dabbled in other medical careers before becoming hospitalists, are another choice.
Doctors in each of these categories are still brimming with energy and enthusiasm for medicine and are a looking for ways to make things better for patients and themselves. They might be your next hospitalist recruit. TH
Look at hospitalists and you’ll find more gray hair, crow’s feet, and accumulated wisdom than you might expect. While many hospitalists are physicians fresh from residency, the average age of a hospitalist is actually 40—in part because some hospitalist are docs who have left office practices in favor of hospital work.
These docs, who we’ll call “mid-career hospitalists,” take diverse paths to this change. Some miss the adrenaline rush of acute care. Others have become weary of the flat reimbursements and high patient volumes needed to maintain office practices today. Whatever their paths, they’re an interesting lot.
The most common scenario by which mid-career hospitalists make a transition is when hospital administrators recruit their own. That’s how Robert Brannon, MD, an Ob/Gyn in private practice since 1968, became a hospitalist at Presbyterian Hospital of Dallas in July 2005. Shrinking reimbursements, the costs of running an office, having to cover night call, and a national request for proposal (RFP) by the hospital precipitated Dr. Brannon’s career move.
He and nine other Ob/Gyns submitted a proposal in response to the RFP; hospital administrators awarded the group, OB on Call, LLP, a contract to start a hospitalist service for a largely indigent population in a hospital with more than 7,000 births annually.
I had already started to phase out the office practice and was working in a Medicaid clinic and an osteoporosis clinic when the hospital decided it had to do better with its indigent patients, particularly the 80 to 90 each month who came in with no prenatal care,” says Dr. Brannon. “The medical staff knew that resident work rules precluded their work off hours, so patient needs indicated that full-time hospitalists were in order.”
Now Dr. Brannon has the camaraderie of working with other hospitalists and neonatologists, delivering many babies, but still eliminating on-call obligations when he’s off duty.
“I’m doing more significant obstetrics work, re-honing my skills, and doing high-risk deliveries,” he says. “I’m doing what I love without the administrative hassles of a private practice.”
Jeffrey Frank, MD, had an even bigger nut to crack when he switched from an office-based practice to start a hospitalist medicine service at Doctors Medical Center (DMC) in San Pablo, Calif. The 45-year-old internist graduated from medical school in 1987 and worked in a four-person medical group in the area he describes as “very industrial, with oil refineries all around and the home base of the Hells Angels.”
—Scott Oxenhandler, MD
Helping to cover hospitalized patients for five HMOs precipitated his career change. “That was a mini-hospitalist assignment, and I felt I could adapt to full-time,” says Dr. Frank.
On DMC’s medical staff for years, Dr. Frank saw the hospital go from first in market share to a distant second after entrepreneurial doctors built a newer hospital north of town. Dr. Frank’s patients were aging and the prospects for improving the office practice were poor. Then there was Dr. Frank’s 800-pound gorilla: Kaiser-Permanente, a giant with 45% market share, with plans geared to younger patients, and physician salaries that his group couldn’t match. DMC continued slowly downhill, with closure a real risk.
In 2004, with his family’s acceptance of the long hours that launching a hospitalist program would take, Dr. Frank initiated discussions with hospital administrators to become its first chief hospitalist. Rather than leaving the office practice and launching a hospitalist service simultaneously, Dr. Frank approached established vendors for help. He chose IPC for its technology infrastructure and electronic medical records, competitive salaries, and the hope of attracting more physicians, whom Dr. Frank eventually recruited locally.
He built the hospitalist patient base by admitting all patients of the two largest medical groups. His entrepreneurial spirit intrigued both IPC and the hospital’s chief financial officer by reducing the average length of stay from 5.3 to 4.0 days, which improved the bottom line. Dr. Frank’s salary then increased by 30%. He says he loves doing acute care again and sees many of his former patients because the medical group has transferred hospital work to the hospitalists.
—Jeffrey Frank, MD
“I was worried about being at the hospital all the time,” says Dr. Frank. “I’m 45 years old, but energetic because there’s lots of work. I can keep up with three of the hospitalists just out of residency. Seeing my old patients also connects me to my old practice.”
Across the country in Hollywood, Fla., Scott Oxenhandler, MD, a geriatrician, couldn’t be happier with his mid-career change from office-based doctor to hospitalist. He left a thriving practice of eight physicians he helped start in 1987 to be chief hospitalist at Hollywood Memorial Regional Hospital (Fla.). Seeing five to eight hospitalized patients every day as their primary physician, he knew the hospital’s inner workings and how to start a hospitalist program—largely for unassigned patients.
“I wanted a free hand practicing acute care medicine, good compensation and benefits, lack of paperwork hassles, and a great schedule,” says Dr. Oxenhandler.
When he started in July 2004 Dr. Oxenhandler had no problem structuring a hospital medicine service that attracted physicians with competitive salaries and schedules to accommodate individual needs. He now has 21 full- and part-time hospitalists. They mostly work 8 a.m. to 5 p.m. with an average daily census of 12 to 15 and several consults. A nocturnist admits patients from 8 p.m. to 8 a.m., and 10 doctors handle 5 p.m. to 8 p.m. short call four times per month.
Overall, the transition for the 48-year-old veteran was surprisingly easy. “I was in the hospital all the time anyway, and the way internal medicine is evolving there have to be connections between inpatient and outpatient doctors,” says Dr. Oxenhandler. As the hospitalist leader he mentors young doctors, knows how to distribute the workload, and loves to share clinical insights.
Other Paths
For a doctor who finished residency at nearly 40, “mid-career change” takes on new meaning. Ron Jacobs, MD, internist, chief medical officer, and co-founder of PrimeDoc Management Services of Asheville, N.C., was a businessman in his 20s, then studied medicine and started an office practice in 1997. That practice—with four internists, a pulmonologist, and a cardiologist—was thriving. But Dr. Jacobs was bored. He missed the hospital’s intensity, was used to visiting six or eight hospitalized patients daily, and decided that seeing 16 or 18 patients without the office practice would suit him. So he co-founded PrimeDoc, which now has 100 hospitalists practicing in 15 programs throughout the Southeast and Mid-Atlantic.
The 49-year-old doctor eases the transition for other mid-lifers, recognizing that avoiding burnout as a hospitalist requires mental and physical preparation.
“The sheer volume of rounding, whether for an [average daily census] of 18 or 13 consults a day is tough,” says Dr. Jacobs. “They’ve got to be solid internists with strong ICU skills. I like diverse teams of older and younger docs. They work well because a team of hospitalists all just out of residency can easily burn out. They need the experience and mentoring of older docs to augment their up-to-date clinical skills.”
Academia is also fertile ground for mid-career changes. A doctor with an office practice and a faculty appointment may someday close the office and return to the hospital he or she loves. (See the profile of Joseph Snitzer, MD: “Sibling Rivalry,” in The Hospitalist, Sept. 2005.) Scott Wilson, MD, of The University of Iowa Hospitals and Clinic, Rapid City, left to start a hospitalist program in 2000 for the 880-bed University Hospital and its 250-bed Veterans Affairs Hospital after many years of teaching in the medical school. Dr. Wilson was tapped to start the hospitalist program because of improvements he had made in educating physicians.
—Ron Jacobs, MD
“Our program has some unique features, particularly our interaction with residents, improving the med school curriculum, and building research into our practice,” says Dr. Wilson.
In 2004 that included a study showing that patients managed by hospitalists had shorter length of stay (LOS) and lower costs than patients managed by non-hospitalists, but had higher costs per day. (Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004 Aug;10 (8):561-568). The schedule’s tough for a non-20-something: call every fourth night, three-week blocks for six months, then six months of research.
Dr. Wilson enjoys the challenge and the $1 million hospital support the program garnered in 2005. “We meet their needs to reduce LOS and improve quality, and we keep growing our program through new tasks such as surgical co-management of orthopedics,” he says.
Recruiting Them
Hospital administrators who want to recruit mid-career physicians as hospitalists need look no further than their own backyards. The internist or family practice doctor who relishes hospital rounds but has to rush back to the office, such as Dr. Oxenhandler, is a prime candidate for hospitalist recruitment. Areas where medical groups have trouble recruiting new doctors because reimbursements are flat (e.g., San Pablo) are also fertile ground for recruiting. Entrepreneurial physicians like Drs. Brannon and Jacobs, who had already dabbled in other medical careers before becoming hospitalists, are another choice.
Doctors in each of these categories are still brimming with energy and enthusiasm for medicine and are a looking for ways to make things better for patients and themselves. They might be your next hospitalist recruit. TH
Look at hospitalists and you’ll find more gray hair, crow’s feet, and accumulated wisdom than you might expect. While many hospitalists are physicians fresh from residency, the average age of a hospitalist is actually 40—in part because some hospitalist are docs who have left office practices in favor of hospital work.
These docs, who we’ll call “mid-career hospitalists,” take diverse paths to this change. Some miss the adrenaline rush of acute care. Others have become weary of the flat reimbursements and high patient volumes needed to maintain office practices today. Whatever their paths, they’re an interesting lot.
The most common scenario by which mid-career hospitalists make a transition is when hospital administrators recruit their own. That’s how Robert Brannon, MD, an Ob/Gyn in private practice since 1968, became a hospitalist at Presbyterian Hospital of Dallas in July 2005. Shrinking reimbursements, the costs of running an office, having to cover night call, and a national request for proposal (RFP) by the hospital precipitated Dr. Brannon’s career move.
He and nine other Ob/Gyns submitted a proposal in response to the RFP; hospital administrators awarded the group, OB on Call, LLP, a contract to start a hospitalist service for a largely indigent population in a hospital with more than 7,000 births annually.
I had already started to phase out the office practice and was working in a Medicaid clinic and an osteoporosis clinic when the hospital decided it had to do better with its indigent patients, particularly the 80 to 90 each month who came in with no prenatal care,” says Dr. Brannon. “The medical staff knew that resident work rules precluded their work off hours, so patient needs indicated that full-time hospitalists were in order.”
Now Dr. Brannon has the camaraderie of working with other hospitalists and neonatologists, delivering many babies, but still eliminating on-call obligations when he’s off duty.
“I’m doing more significant obstetrics work, re-honing my skills, and doing high-risk deliveries,” he says. “I’m doing what I love without the administrative hassles of a private practice.”
Jeffrey Frank, MD, had an even bigger nut to crack when he switched from an office-based practice to start a hospitalist medicine service at Doctors Medical Center (DMC) in San Pablo, Calif. The 45-year-old internist graduated from medical school in 1987 and worked in a four-person medical group in the area he describes as “very industrial, with oil refineries all around and the home base of the Hells Angels.”
—Scott Oxenhandler, MD
Helping to cover hospitalized patients for five HMOs precipitated his career change. “That was a mini-hospitalist assignment, and I felt I could adapt to full-time,” says Dr. Frank.
On DMC’s medical staff for years, Dr. Frank saw the hospital go from first in market share to a distant second after entrepreneurial doctors built a newer hospital north of town. Dr. Frank’s patients were aging and the prospects for improving the office practice were poor. Then there was Dr. Frank’s 800-pound gorilla: Kaiser-Permanente, a giant with 45% market share, with plans geared to younger patients, and physician salaries that his group couldn’t match. DMC continued slowly downhill, with closure a real risk.
In 2004, with his family’s acceptance of the long hours that launching a hospitalist program would take, Dr. Frank initiated discussions with hospital administrators to become its first chief hospitalist. Rather than leaving the office practice and launching a hospitalist service simultaneously, Dr. Frank approached established vendors for help. He chose IPC for its technology infrastructure and electronic medical records, competitive salaries, and the hope of attracting more physicians, whom Dr. Frank eventually recruited locally.
He built the hospitalist patient base by admitting all patients of the two largest medical groups. His entrepreneurial spirit intrigued both IPC and the hospital’s chief financial officer by reducing the average length of stay from 5.3 to 4.0 days, which improved the bottom line. Dr. Frank’s salary then increased by 30%. He says he loves doing acute care again and sees many of his former patients because the medical group has transferred hospital work to the hospitalists.
—Jeffrey Frank, MD
“I was worried about being at the hospital all the time,” says Dr. Frank. “I’m 45 years old, but energetic because there’s lots of work. I can keep up with three of the hospitalists just out of residency. Seeing my old patients also connects me to my old practice.”
Across the country in Hollywood, Fla., Scott Oxenhandler, MD, a geriatrician, couldn’t be happier with his mid-career change from office-based doctor to hospitalist. He left a thriving practice of eight physicians he helped start in 1987 to be chief hospitalist at Hollywood Memorial Regional Hospital (Fla.). Seeing five to eight hospitalized patients every day as their primary physician, he knew the hospital’s inner workings and how to start a hospitalist program—largely for unassigned patients.
“I wanted a free hand practicing acute care medicine, good compensation and benefits, lack of paperwork hassles, and a great schedule,” says Dr. Oxenhandler.
When he started in July 2004 Dr. Oxenhandler had no problem structuring a hospital medicine service that attracted physicians with competitive salaries and schedules to accommodate individual needs. He now has 21 full- and part-time hospitalists. They mostly work 8 a.m. to 5 p.m. with an average daily census of 12 to 15 and several consults. A nocturnist admits patients from 8 p.m. to 8 a.m., and 10 doctors handle 5 p.m. to 8 p.m. short call four times per month.
Overall, the transition for the 48-year-old veteran was surprisingly easy. “I was in the hospital all the time anyway, and the way internal medicine is evolving there have to be connections between inpatient and outpatient doctors,” says Dr. Oxenhandler. As the hospitalist leader he mentors young doctors, knows how to distribute the workload, and loves to share clinical insights.
Other Paths
For a doctor who finished residency at nearly 40, “mid-career change” takes on new meaning. Ron Jacobs, MD, internist, chief medical officer, and co-founder of PrimeDoc Management Services of Asheville, N.C., was a businessman in his 20s, then studied medicine and started an office practice in 1997. That practice—with four internists, a pulmonologist, and a cardiologist—was thriving. But Dr. Jacobs was bored. He missed the hospital’s intensity, was used to visiting six or eight hospitalized patients daily, and decided that seeing 16 or 18 patients without the office practice would suit him. So he co-founded PrimeDoc, which now has 100 hospitalists practicing in 15 programs throughout the Southeast and Mid-Atlantic.
The 49-year-old doctor eases the transition for other mid-lifers, recognizing that avoiding burnout as a hospitalist requires mental and physical preparation.
“The sheer volume of rounding, whether for an [average daily census] of 18 or 13 consults a day is tough,” says Dr. Jacobs. “They’ve got to be solid internists with strong ICU skills. I like diverse teams of older and younger docs. They work well because a team of hospitalists all just out of residency can easily burn out. They need the experience and mentoring of older docs to augment their up-to-date clinical skills.”
Academia is also fertile ground for mid-career changes. A doctor with an office practice and a faculty appointment may someday close the office and return to the hospital he or she loves. (See the profile of Joseph Snitzer, MD: “Sibling Rivalry,” in The Hospitalist, Sept. 2005.) Scott Wilson, MD, of The University of Iowa Hospitals and Clinic, Rapid City, left to start a hospitalist program in 2000 for the 880-bed University Hospital and its 250-bed Veterans Affairs Hospital after many years of teaching in the medical school. Dr. Wilson was tapped to start the hospitalist program because of improvements he had made in educating physicians.
—Ron Jacobs, MD
“Our program has some unique features, particularly our interaction with residents, improving the med school curriculum, and building research into our practice,” says Dr. Wilson.
In 2004 that included a study showing that patients managed by hospitalists had shorter length of stay (LOS) and lower costs than patients managed by non-hospitalists, but had higher costs per day. (Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004 Aug;10 (8):561-568). The schedule’s tough for a non-20-something: call every fourth night, three-week blocks for six months, then six months of research.
Dr. Wilson enjoys the challenge and the $1 million hospital support the program garnered in 2005. “We meet their needs to reduce LOS and improve quality, and we keep growing our program through new tasks such as surgical co-management of orthopedics,” he says.
Recruiting Them
Hospital administrators who want to recruit mid-career physicians as hospitalists need look no further than their own backyards. The internist or family practice doctor who relishes hospital rounds but has to rush back to the office, such as Dr. Oxenhandler, is a prime candidate for hospitalist recruitment. Areas where medical groups have trouble recruiting new doctors because reimbursements are flat (e.g., San Pablo) are also fertile ground for recruiting. Entrepreneurial physicians like Drs. Brannon and Jacobs, who had already dabbled in other medical careers before becoming hospitalists, are another choice.
Doctors in each of these categories are still brimming with energy and enthusiasm for medicine and are a looking for ways to make things better for patients and themselves. They might be your next hospitalist recruit. TH