Remember the classic episod-es of “Star Trek” where a new cast member went on a mission? Chances were that guy would be the one to fall off a cliff or get zapped with a laser gun and would not make it back safely to the starship Enterprise.

Recently I was in a meeting focused on what happens when older adults are discharged from the hospital. I thought to myself: “Those are the patients wearing the red uniforms. But what if we could make the experience of older adults more like that of Spock and Captain Kirk, where luck and good preparation are on their side and the data to make informed decisions follow them everywhere?”

The transition of patients in and out of the hospital has become a key patient-safety concern. Patients frequently arrive at the hospital with incomplete medical histories and uncertain or missing medication lists. During a typical hospitalization, patients receive less than optimal preparation before their discharge and often leave the hospital without a clear understanding of how to care for themselves, identify new symptoms that require immediate medical attention, or take their medications. Further, it is often unclear whom patients should call with questions while they are in “the white space”—that time period between hospital discharge and follow-up care. Do they call the hospital? The hospitalist? Their primary care physician? Their cardiologist?

Safety related to transitions of care is a concern frequently raised about the hospital medicine movement. The use of hospitalists forces physician discontinuity at admission and discharge. However, SHM plans to make discharge planning an issue that brings hospitalists and hospital medicine the greatest praise. SHM is taking a clear, proactive leadership role to define safe transitions, create toolkits for hospitals to improve their current transition practices, and develop technical assistance programs to build quality improvement capacity at local institutions.

Safe Transitions

SHM is participating in two major initiatives to define safe transitions. As a member of the American Board of Internal Medicine (ABIM) Foundation Stepping Up To The Plate Initiative (SUTTP), we are helping to develop sets of principles of and standards for safe and effective transitions.

SHM also co-chaired a Transitions of Care Consensus Conference (TOCCC) in partnership with the American College of Physicians and Society of General Internal Medicine. The TOCCC further reviewed the work of the SUTTP conference and focused more specifically on issues that arise as patients transfer in and out of the hospital.

In these meetings and others, SHM’s messages were clear:

• Improvements in transitions are needed now, and shouldn’t wait for other movements such as creation of medical homes or national electronic medical records to become a reality;
• Safe transitions require teams of medical professionals on both sides of the transfer and patients and their families working together;
• Patients and their families/ caregivers must be included and prepared for transfers of care;
• Better information on patient history and medications needs to follow patients into the hospital; and
• A small subset of information from the care plan, or transition record, should follow patients through each transfer, and be made available to them in lay terms.

Both the SUTTP and TOCCC documents are under review for endorsement by multiple medical professional societies. SHM is pursuing the development of related performance measures for safe care transitions.

Technical Assistance

SHM has for years distinguished its educational offerings by offering “implementation education.” We focus on translating best practices into actual practices. To that end, with generous support from the John A. Hartford Foundation, we are developing a discharge planning toolkit.

The toolkit will provide a step-wise approach to plan, implement, and evaluate interventions to improve discharge planning. The toolkit will help quality teams establish goals, garner internal support for interventions, educate support staff, and evaluate their results.

The interventional approaches and tools are focused on:

• Improving communication among sending and receiving physicians;
• Better preparing patients for post-discharge medication management and other self-care; and
• Facilitating follow-up care and transfer of patient information.

On Sept. 7, SHM convened an advisory board in Chicago to review and provide feedback on our proposed interventional strategies, technical support offerings, and evaluation plan. An impressive group of key stakeholders attended, including:

• Representatives from major payer groups such as the Centers for Medicare and Medicaid Services, Blue Cross Blue Shield, and Kaiser Permanente;
• Professional societies including the American Geriatrics Society, the Society of General Internal Medicine, the Case Management Society of America, and the American Society of Health System Pharmacists.
• Representation from the John A. Hartford Foundation, patient advocates from The Families and Health Care Project, and leaders and practicing professionals in nursing, social work, case management, patient advocacy, geriatrics, primary care, quality improvement and, of course, hospital medicine.

While not at the September meeting, the advisory board also includes representatives from the Agency for Healthcare Research and Quality and the Joint Commission.

The advisory board provided valuable feedback on SHM’s proposed toolkit and applauded our efforts to lead teams to make substantial local hospital improvements. Participants also had the opportunity to share existing resources and strategize opportunities to encourage wide-scale adoption of the toolkit. In February the advisory board plans to reconvene to review the completed toolkit.

SHM is developing training opportunities for institutions adopting the toolkit, designed to meet the full spectrum of technical assistance needs. The full toolkit will be available free on SHM’s Web site in the spring. At the April 2008 SHM Annual Meeting in San Diego, quality teams can participate in a daylong pre-course on general quality improvement principles and hands-on application of the toolkit.

In May, SHM will begin reviewing applications for sites wishing to participate in the yearlong mentoring program or a more intensive short-term, on-site consultant service. For more information on these technical assistance programs, visit the SHM Web site at www.hospitalmedicine.org and select the “Quality Improvement” link, then “Current Initiatives.”

We hope you and your institution will join our journey into the white space to improve discharge planning and help our patients “live long and prosper.” TH

Remember the classic episod-es of “Star Trek” where a new cast member went on a mission? Chances were that guy would be the one to fall off a cliff or get zapped with a laser gun and would not make it back safely to the starship Enterprise.

Recently I was in a meeting focused on what happens when older adults are discharged from the hospital. I thought to myself: “Those are the patients wearing the red uniforms. But what if we could make the experience of older adults more like that of Spock and Captain Kirk, where luck and good preparation are on their side and the data to make informed decisions follow them everywhere?”

The transition of patients in and out of the hospital has become a key patient-safety concern. Patients frequently arrive at the hospital with incomplete medical histories and uncertain or missing medication lists. During a typical hospitalization, patients receive less than optimal preparation before their discharge and often leave the hospital without a clear understanding of how to care for themselves, identify new symptoms that require immediate medical attention, or take their medications. Further, it is often unclear whom patients should call with questions while they are in “the white space”—that time period between hospital discharge and follow-up care. Do they call the hospital? The hospitalist? Their primary care physician? Their cardiologist?

Safety related to transitions of care is a concern frequently raised about the hospital medicine movement. The use of hospitalists forces physician discontinuity at admission and discharge. However, SHM plans to make discharge planning an issue that brings hospitalists and hospital medicine the greatest praise. SHM is taking a clear, proactive leadership role to define safe transitions, create toolkits for hospitals to improve their current transition practices, and develop technical assistance programs to build quality improvement capacity at local institutions.

Safe Transitions

SHM is participating in two major initiatives to define safe transitions. As a member of the American Board of Internal Medicine (ABIM) Foundation Stepping Up To The Plate Initiative (SUTTP), we are helping to develop sets of principles of and standards for safe and effective transitions.

SHM also co-chaired a Transitions of Care Consensus Conference (TOCCC) in partnership with the American College of Physicians and Society of General Internal Medicine. The TOCCC further reviewed the work of the SUTTP conference and focused more specifically on issues that arise as patients transfer in and out of the hospital.

In these meetings and others, SHM’s messages were clear:

• Improvements in transitions are needed now, and shouldn’t wait for other movements such as creation of medical homes or national electronic medical records to become a reality;
• Safe transitions require teams of medical professionals on both sides of the transfer and patients and their families working together;
• Patients and their families/ caregivers must be included and prepared for transfers of care;
• Better information on patient history and medications needs to follow patients into the hospital; and
• A small subset of information from the care plan, or transition record, should follow patients through each transfer, and be made available to them in lay terms.

Both the SUTTP and TOCCC documents are under review for endorsement by multiple medical professional societies. SHM is pursuing the development of related performance measures for safe care transitions.

Technical Assistance

SHM has for years distinguished its educational offerings by offering “implementation education.” We focus on translating best practices into actual practices. To that end, with generous support from the John A. Hartford Foundation, we are developing a discharge planning toolkit.

The toolkit will provide a step-wise approach to plan, implement, and evaluate interventions to improve discharge planning. The toolkit will help quality teams establish goals, garner internal support for interventions, educate support staff, and evaluate their results.

The interventional approaches and tools are focused on:

• Improving communication among sending and receiving physicians;
• Better preparing patients for post-discharge medication management and other self-care; and
• Facilitating follow-up care and transfer of patient information.

On Sept. 7, SHM convened an advisory board in Chicago to review and provide feedback on our proposed interventional strategies, technical support offerings, and evaluation plan. An impressive group of key stakeholders attended, including:

• Representatives from major payer groups such as the Centers for Medicare and Medicaid Services, Blue Cross Blue Shield, and Kaiser Permanente;
• Professional societies including the American Geriatrics Society, the Society of General Internal Medicine, the Case Management Society of America, and the American Society of Health System Pharmacists.
• Representation from the John A. Hartford Foundation, patient advocates from The Families and Health Care Project, and leaders and practicing professionals in nursing, social work, case management, patient advocacy, geriatrics, primary care, quality improvement and, of course, hospital medicine.

While not at the September meeting, the advisory board also includes representatives from the Agency for Healthcare Research and Quality and the Joint Commission.

The advisory board provided valuable feedback on SHM’s proposed toolkit and applauded our efforts to lead teams to make substantial local hospital improvements. Participants also had the opportunity to share existing resources and strategize opportunities to encourage wide-scale adoption of the toolkit. In February the advisory board plans to reconvene to review the completed toolkit.

SHM is developing training opportunities for institutions adopting the toolkit, designed to meet the full spectrum of technical assistance needs. The full toolkit will be available free on SHM’s Web site in the spring. At the April 2008 SHM Annual Meeting in San Diego, quality teams can participate in a daylong pre-course on general quality improvement principles and hands-on application of the toolkit.

In May, SHM will begin reviewing applications for sites wishing to participate in the yearlong mentoring program or a more intensive short-term, on-site consultant service. For more information on these technical assistance programs, visit the SHM Web site at www.hospitalmedicine.org and select the “Quality Improvement” link, then “Current Initiatives.”

We hope you and your institution will join our journey into the white space to improve discharge planning and help our patients “live long and prosper.” TH

Remember the classic episod-es of “Star Trek” where a new cast member went on a mission? Chances were that guy would be the one to fall off a cliff or get zapped with a laser gun and would not make it back safely to the starship Enterprise.

Recently I was in a meeting focused on what happens when older adults are discharged from the hospital. I thought to myself: “Those are the patients wearing the red uniforms. But what if we could make the experience of older adults more like that of Spock and Captain Kirk, where luck and good preparation are on their side and the data to make informed decisions follow them everywhere?”

The transition of patients in and out of the hospital has become a key patient-safety concern. Patients frequently arrive at the hospital with incomplete medical histories and uncertain or missing medication lists. During a typical hospitalization, patients receive less than optimal preparation before their discharge and often leave the hospital without a clear understanding of how to care for themselves, identify new symptoms that require immediate medical attention, or take their medications. Further, it is often unclear whom patients should call with questions while they are in “the white space”—that time period between hospital discharge and follow-up care. Do they call the hospital? The hospitalist? Their primary care physician? Their cardiologist?

Safety related to transitions of care is a concern frequently raised about the hospital medicine movement. The use of hospitalists forces physician discontinuity at admission and discharge. However, SHM plans to make discharge planning an issue that brings hospitalists and hospital medicine the greatest praise. SHM is taking a clear, proactive leadership role to define safe transitions, create toolkits for hospitals to improve their current transition practices, and develop technical assistance programs to build quality improvement capacity at local institutions.

Safe Transitions

SHM is participating in two major initiatives to define safe transitions. As a member of the American Board of Internal Medicine (ABIM) Foundation Stepping Up To The Plate Initiative (SUTTP), we are helping to develop sets of principles of and standards for safe and effective transitions.

SHM also co-chaired a Transitions of Care Consensus Conference (TOCCC) in partnership with the American College of Physicians and Society of General Internal Medicine. The TOCCC further reviewed the work of the SUTTP conference and focused more specifically on issues that arise as patients transfer in and out of the hospital.

In these meetings and others, SHM’s messages were clear:

• Improvements in transitions are needed now, and shouldn’t wait for other movements such as creation of medical homes or national electronic medical records to become a reality;
• Safe transitions require teams of medical professionals on both sides of the transfer and patients and their families working together;
• Patients and their families/ caregivers must be included and prepared for transfers of care;
• Better information on patient history and medications needs to follow patients into the hospital; and
• A small subset of information from the care plan, or transition record, should follow patients through each transfer, and be made available to them in lay terms.

Both the SUTTP and TOCCC documents are under review for endorsement by multiple medical professional societies. SHM is pursuing the development of related performance measures for safe care transitions.

Technical Assistance

SHM has for years distinguished its educational offerings by offering “implementation education.” We focus on translating best practices into actual practices. To that end, with generous support from the John A. Hartford Foundation, we are developing a discharge planning toolkit.

The toolkit will provide a step-wise approach to plan, implement, and evaluate interventions to improve discharge planning. The toolkit will help quality teams establish goals, garner internal support for interventions, educate support staff, and evaluate their results.

The interventional approaches and tools are focused on:

• Improving communication among sending and receiving physicians;
• Better preparing patients for post-discharge medication management and other self-care; and
• Facilitating follow-up care and transfer of patient information.

On Sept. 7, SHM convened an advisory board in Chicago to review and provide feedback on our proposed interventional strategies, technical support offerings, and evaluation plan. An impressive group of key stakeholders attended, including:

• Representatives from major payer groups such as the Centers for Medicare and Medicaid Services, Blue Cross Blue Shield, and Kaiser Permanente;
• Professional societies including the American Geriatrics Society, the Society of General Internal Medicine, the Case Management Society of America, and the American Society of Health System Pharmacists.
• Representation from the John A. Hartford Foundation, patient advocates from The Families and Health Care Project, and leaders and practicing professionals in nursing, social work, case management, patient advocacy, geriatrics, primary care, quality improvement and, of course, hospital medicine.

While not at the September meeting, the advisory board also includes representatives from the Agency for Healthcare Research and Quality and the Joint Commission.

The advisory board provided valuable feedback on SHM’s proposed toolkit and applauded our efforts to lead teams to make substantial local hospital improvements. Participants also had the opportunity to share existing resources and strategize opportunities to encourage wide-scale adoption of the toolkit. In February the advisory board plans to reconvene to review the completed toolkit.

SHM is developing training opportunities for institutions adopting the toolkit, designed to meet the full spectrum of technical assistance needs. The full toolkit will be available free on SHM’s Web site in the spring. At the April 2008 SHM Annual Meeting in San Diego, quality teams can participate in a daylong pre-course on general quality improvement principles and hands-on application of the toolkit.

In May, SHM will begin reviewing applications for sites wishing to participate in the yearlong mentoring program or a more intensive short-term, on-site consultant service. For more information on these technical assistance programs, visit the SHM Web site at www.hospitalmedicine.org and select the “Quality Improvement” link, then “Current Initiatives.”

We hope you and your institution will join our journey into the white space to improve discharge planning and help our patients “live long and prosper.” TH

Measure Up

Question: I’m a new graduate who just took a job as a hospitalist. I’m hearing a lot about the importance of compliance with the “Core Measures.” Can you explain to me what they are and why these seem to be so important?

Measure for Measure,

Austin, Texas

Dr. Hospitalist responds: As a federal agency, the Center for Medicare and Medicaid Services (CMS) is the largest payer of healthcare in the country. In 2003, it required hospitals that receive CMS payments to report data on the quality of care Medicare recipients received for several inpatient diagnoses (myocardial infarction, heart failure, and community-acquired pneumonia).

CMS enacted this requirement because there was evidence to suggest hospitalized patients were not uniformly receiving evidence-based care.

For example, I am unaware of any healthcare providers who would question the routine use of aspirin in patients who present with acute myocardial infarction. Despite this widespread knowledge, CMS audits found this practice was not uniform among hospitals nationwide. More detailed analysis suggested this inconsistency was not usually because of ignorant providers but more often a lack of systems to ensure uniform care for all patients at all times.

Since 2003, CMS has expanded the number of Core Quality Measures hospitals must report. For example, the present quality measures for community-acquired pneumonia include:

• Initial antibiotics within four hours of hospital presentation;
• Oxygen assessment;
• Blood culture before first antibiotic dose;
• Appropriate initial antibiotic selection;
• Smoking cessation counseling;
• Influenza vaccination for inpatients from October through February; and
• Pneumococcal vaccination for patients 65 and older.

This year, CMS raised the stakes by tying reimbursement to performance on these quality measures. I can assure you the few hospitals around the country that hadn’t addressed this issue have done so today. The risk of losing CMS funding is not an option for most hospitals. In many cases, the hospitals have turned to providers in location-based specialties (e.g., emergency department providers, hospitalists, and intensivists) as partners in the development, implementation, and enforcement of these quality measures. These providers are uniquely positioned to address performance on these quality measures.

Well Rounded

Question: Do you have any suggestions on how to improve communications between hospitalists and other inpatient providers like nurses and case managers?

Let’s Talk,

Madison, Wis.

Dr. Hospitalist responds: If your hospitalist program is not conducting multidisciplinary rounds, consider them.

The primary goal is interdisciplinary communication. Conduct these rounds at least once each morning, as early as possible after nursing shift change and hospitalist hand-off. Participants should include hospitalists, nurses, and case managers at a minimum. Some programs include other providers like nurses’ aides, pharmacists, physical/occupational therapists, social workers, and dietitians.

During rounds, the hospitalist leads a brief discussion about the plan of care for each patient, soliciting feedback from all participants. Discussions should last no longer than two-three minutes apiece and often are shorter. The occasional patient whose issues demand a longer discussion should be treated as an outlier and discussed at the end of rounds.

Nonphysician providers should solicit written physician orders during rounds. The team should consider barriers to discharge and identify ways to overcome those barriers. At the conclusion of rounds, each participant should leave with a clear understanding of each patient’s plan of care for that day and for the hospital stay. Hospitalists should leave rounds able to prioritize the order of patient care. They should see the sickest patients first, then potential early discharges, then everyone else.

Rounds can fail for several reasons. Watch for the signs and address them before the rounds spiral out of control:

• Participants are late: It is vital to set the expectation that everyone will show up on time. Without that, the start time for rounds will drift from day to day and waste time;
• Participants come unprepared: Taking part at rounds requires that the nurse leaves nursing hand-off with the necessary information to participate effectively. This is the same for the hospitalist with morning hand-off from the doctor who worked overnight. Without sufficient information, participants will find themselves with nothing to say—or worse, provide erroneous or useless information; or
• Participants stray off the topic: It is easy to digress during group discussions. As the rounds leader, the hospitalist must keep discussion pertinent so rounds are not prolonged with unnecessary discussion. Think of rounds as an investment. We are asking busy providers to take 30 minutes out of their busy schedule to talk about patient care. A wise investment saves providers more time than they invested.

A primary benefit of rounds is as a forum for communication. All providers should try to funnel communication toward rounds rather than stopping the doctor or nurse throughout the day with questions and comments. Minimizing interruptions will foster more efficient care. Some hospitalist programs even huddle briefly in the afternoon to review plans discussed at morning rounds. TH

Measure Up

Question: I’m a new graduate who just took a job as a hospitalist. I’m hearing a lot about the importance of compliance with the “Core Measures.” Can you explain to me what they are and why these seem to be so important?

Measure for Measure,

Austin, Texas

Dr. Hospitalist responds: As a federal agency, the Center for Medicare and Medicaid Services (CMS) is the largest payer of healthcare in the country. In 2003, it required hospitals that receive CMS payments to report data on the quality of care Medicare recipients received for several inpatient diagnoses (myocardial infarction, heart failure, and community-acquired pneumonia).

CMS enacted this requirement because there was evidence to suggest hospitalized patients were not uniformly receiving evidence-based care.

For example, I am unaware of any healthcare providers who would question the routine use of aspirin in patients who present with acute myocardial infarction. Despite this widespread knowledge, CMS audits found this practice was not uniform among hospitals nationwide. More detailed analysis suggested this inconsistency was not usually because of ignorant providers but more often a lack of systems to ensure uniform care for all patients at all times.

Since 2003, CMS has expanded the number of Core Quality Measures hospitals must report. For example, the present quality measures for community-acquired pneumonia include:

• Initial antibiotics within four hours of hospital presentation;
• Oxygen assessment;
• Blood culture before first antibiotic dose;
• Appropriate initial antibiotic selection;
• Smoking cessation counseling;
• Influenza vaccination for inpatients from October through February; and
• Pneumococcal vaccination for patients 65 and older.

This year, CMS raised the stakes by tying reimbursement to performance on these quality measures. I can assure you the few hospitals around the country that hadn’t addressed this issue have done so today. The risk of losing CMS funding is not an option for most hospitals. In many cases, the hospitals have turned to providers in location-based specialties (e.g., emergency department providers, hospitalists, and intensivists) as partners in the development, implementation, and enforcement of these quality measures. These providers are uniquely positioned to address performance on these quality measures.

Well Rounded

Question: Do you have any suggestions on how to improve communications between hospitalists and other inpatient providers like nurses and case managers?

Let’s Talk,

Madison, Wis.

Dr. Hospitalist responds: If your hospitalist program is not conducting multidisciplinary rounds, consider them.

The primary goal is interdisciplinary communication. Conduct these rounds at least once each morning, as early as possible after nursing shift change and hospitalist hand-off. Participants should include hospitalists, nurses, and case managers at a minimum. Some programs include other providers like nurses’ aides, pharmacists, physical/occupational therapists, social workers, and dietitians.

During rounds, the hospitalist leads a brief discussion about the plan of care for each patient, soliciting feedback from all participants. Discussions should last no longer than two-three minutes apiece and often are shorter. The occasional patient whose issues demand a longer discussion should be treated as an outlier and discussed at the end of rounds.

Nonphysician providers should solicit written physician orders during rounds. The team should consider barriers to discharge and identify ways to overcome those barriers. At the conclusion of rounds, each participant should leave with a clear understanding of each patient’s plan of care for that day and for the hospital stay. Hospitalists should leave rounds able to prioritize the order of patient care. They should see the sickest patients first, then potential early discharges, then everyone else.

Rounds can fail for several reasons. Watch for the signs and address them before the rounds spiral out of control:

• Participants are late: It is vital to set the expectation that everyone will show up on time. Without that, the start time for rounds will drift from day to day and waste time;
• Participants come unprepared: Taking part at rounds requires that the nurse leaves nursing hand-off with the necessary information to participate effectively. This is the same for the hospitalist with morning hand-off from the doctor who worked overnight. Without sufficient information, participants will find themselves with nothing to say—or worse, provide erroneous or useless information; or
• Participants stray off the topic: It is easy to digress during group discussions. As the rounds leader, the hospitalist must keep discussion pertinent so rounds are not prolonged with unnecessary discussion. Think of rounds as an investment. We are asking busy providers to take 30 minutes out of their busy schedule to talk about patient care. A wise investment saves providers more time than they invested.

A primary benefit of rounds is as a forum for communication. All providers should try to funnel communication toward rounds rather than stopping the doctor or nurse throughout the day with questions and comments. Minimizing interruptions will foster more efficient care. Some hospitalist programs even huddle briefly in the afternoon to review plans discussed at morning rounds. TH

Measure Up

Question: I’m a new graduate who just took a job as a hospitalist. I’m hearing a lot about the importance of compliance with the “Core Measures.” Can you explain to me what they are and why these seem to be so important?

Measure for Measure,

Austin, Texas

Dr. Hospitalist responds: As a federal agency, the Center for Medicare and Medicaid Services (CMS) is the largest payer of healthcare in the country. In 2003, it required hospitals that receive CMS payments to report data on the quality of care Medicare recipients received for several inpatient diagnoses (myocardial infarction, heart failure, and community-acquired pneumonia).

CMS enacted this requirement because there was evidence to suggest hospitalized patients were not uniformly receiving evidence-based care.

For example, I am unaware of any healthcare providers who would question the routine use of aspirin in patients who present with acute myocardial infarction. Despite this widespread knowledge, CMS audits found this practice was not uniform among hospitals nationwide. More detailed analysis suggested this inconsistency was not usually because of ignorant providers but more often a lack of systems to ensure uniform care for all patients at all times.

Since 2003, CMS has expanded the number of Core Quality Measures hospitals must report. For example, the present quality measures for community-acquired pneumonia include:

• Initial antibiotics within four hours of hospital presentation;
• Oxygen assessment;
• Blood culture before first antibiotic dose;
• Appropriate initial antibiotic selection;
• Smoking cessation counseling;
• Influenza vaccination for inpatients from October through February; and
• Pneumococcal vaccination for patients 65 and older.

This year, CMS raised the stakes by tying reimbursement to performance on these quality measures. I can assure you the few hospitals around the country that hadn’t addressed this issue have done so today. The risk of losing CMS funding is not an option for most hospitals. In many cases, the hospitals have turned to providers in location-based specialties (e.g., emergency department providers, hospitalists, and intensivists) as partners in the development, implementation, and enforcement of these quality measures. These providers are uniquely positioned to address performance on these quality measures.

Well Rounded

Question: Do you have any suggestions on how to improve communications between hospitalists and other inpatient providers like nurses and case managers?

Let’s Talk,

Madison, Wis.

Dr. Hospitalist responds: If your hospitalist program is not conducting multidisciplinary rounds, consider them.

The primary goal is interdisciplinary communication. Conduct these rounds at least once each morning, as early as possible after nursing shift change and hospitalist hand-off. Participants should include hospitalists, nurses, and case managers at a minimum. Some programs include other providers like nurses’ aides, pharmacists, physical/occupational therapists, social workers, and dietitians.

During rounds, the hospitalist leads a brief discussion about the plan of care for each patient, soliciting feedback from all participants. Discussions should last no longer than two-three minutes apiece and often are shorter. The occasional patient whose issues demand a longer discussion should be treated as an outlier and discussed at the end of rounds.

Nonphysician providers should solicit written physician orders during rounds. The team should consider barriers to discharge and identify ways to overcome those barriers. At the conclusion of rounds, each participant should leave with a clear understanding of each patient’s plan of care for that day and for the hospital stay. Hospitalists should leave rounds able to prioritize the order of patient care. They should see the sickest patients first, then potential early discharges, then everyone else.

Rounds can fail for several reasons. Watch for the signs and address them before the rounds spiral out of control:

• Participants are late: It is vital to set the expectation that everyone will show up on time. Without that, the start time for rounds will drift from day to day and waste time;
• Participants come unprepared: Taking part at rounds requires that the nurse leaves nursing hand-off with the necessary information to participate effectively. This is the same for the hospitalist with morning hand-off from the doctor who worked overnight. Without sufficient information, participants will find themselves with nothing to say—or worse, provide erroneous or useless information; or
• Participants stray off the topic: It is easy to digress during group discussions. As the rounds leader, the hospitalist must keep discussion pertinent so rounds are not prolonged with unnecessary discussion. Think of rounds as an investment. We are asking busy providers to take 30 minutes out of their busy schedule to talk about patient care. A wise investment saves providers more time than they invested.

A primary benefit of rounds is as a forum for communication. All providers should try to funnel communication toward rounds rather than stopping the doctor or nurse throughout the day with questions and comments. Minimizing interruptions will foster more efficient care. Some hospitalist programs even huddle briefly in the afternoon to review plans discussed at morning rounds. TH

The latest estimates from the National Coalition on Health Care (www.nchc.org/facts/coverage.shtml) show that 46 million Americans—nearly 16% of the population—have no health insurance, and those numbers are increasing. The federal government has been flirting with addressing this growing problem for years, but 2007 may be the turning point, when key legislation may help turn the rising tide of uninsured and underinsured patients.

“A couple of things create a more favorable milieu for this,” explains Eric Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis., and chair of SHM’s Public Policy Committee. “The first is that Massachusetts did it on their own—states are no longer waiting for Congress to do something. The second is that, with every passing year, there’s increased pressure to do something.”

Regardless of why this is happening now, some promising legislation has been introduced in Congress that may provide the beginnings of a solution.

The Health Partnership Act

Perhaps the most promising legislation on healthcare access is an innovative, bipartisan, bicameral effort known as the Health Partnership Act, which proposes a federal-state partnership to address the issue.

Identical bills have been introduced in each house. The Health Partnership Act (S. 325) was introduced in the Senate by Jeff Bingaman (D-N.M.) and George Voinovich (R-Ohio), and the Health Partnership Act through Creative Federalism (HR 506) was introduced in the House by Tammy Baldwin (D-Wis.), Tom Price (R-Ga.), and John Tierney (D-Mass.). Similar legislation was introduced by some of these same parties in the last Congress; though the bill died before action was taken, it was immediately reintroduced in the new Congress this January.

If enacted, the Health Partnership Act would give state and local governments the opportunity to implement their own solutions for providing coverage to uninsured populations, allowing them to address the unique needs that exist within their boundaries. Interested states, groups of states, or even parts of states would apply for five-year federal grants by submitting proposals that demonstrate how their plans would reduce the number of uninsured and improve healthcare quality. Each plan would include information on the appropriate use of information technology to improve the availability of evidence-based medical and outcomes data to providers and patients.

The act would establish a new bipartisan State Health Innovation Commission (SHIC), which would be part of the Department of Health and Human Services. This commission would review the state proposals and submit to Congress a list of recommended applications. It would also work with an established organization—possibly the Institute of Medicine—to develop performance measures and goals regarding coverage, quality, and cost of state programs.

Participating states would eventually report their progress to the SHIC, which would then report to Congress on whether each state was meeting the goals of the act and would then recommend further action.

Giving individual states the flexibility to create their own programs could generate new ideas and would ultimately reveal which programs work best. “We’re not expecting states to hit the ball out of the park the first time, but it’s a start,” says Dr. Siegal. “It’s a step in the right direction.”

SHM supports the Health Partnership Act and has sent a letter of support to Senate sponsors. “This [legislation] may or may not be the most expedient way to get it done,” says Dr. Siegal. “But SHM supports this legislation and is currently drafting a letter of support for the House version.”

The Healthy Americans Act

Another, more comprehensive, bill was introduced in the Senate by Ron Wyden (D-Ore.) in December 2006.

The Healthy Americans Act would require businesses to replace their current health benefits with an increase in wages equal to the amount spent on health insurance premiums. It would require all employees to use these increased wages to purchase their own health plans and would provide subsidies to low-income workers to help pay their premiums.

Those employers not currently providing any health benefits would be required to begin making phased-in “Employer Shared Responsibility Payments,” which would be used to ensure that everyone is able to afford their health plans by funding premium reductions.

Wyden’s bill would have each state establish a Health Help Agency to educate residents about private health plans, to administer enrollment, and to assist income-eligible enrollees with sliding scale premium reductions. These agencies would be funded by the federal government and insurance companies.

Finally, insurance companies would be required to cover every individual who chooses to enroll and would not be allowed to raise prices or deny coverage if individuals are sick.

Some State-Level Solutions

Some states—Massachusetts, for one—have already taken action, implementing their own innovative policies and programs to expand coverage for their populations. Maine, Massachusetts, and Vermont have instituted comprehensive healthcare reform; Arkansas, Montana, New Mexico, Oklahoma, Rhode Island, Tennessee, and Utah have all implemented some form of public-private partnerships; and Illinois and Pennsylvania have initiatives that cover all children.

Maine, Massachusetts, and Vermont all use Medicaid funds to partially subsidize healthcare coverage for families with annual incomes as high as $53,000.

For details on all current state initiatives for healthcare coverage, download the report “State of the States 2007: Building Hope, Raising Expectations” from the Web site of the State Coverage Initiatives at www.statecoverage.net.

Why Hospitalists Should Care

Providing healthcare coverage to the uninsured is one of SHM’s public policy priorities. “There really is a crisis out there, and hospitalists are on the front line of it every day,” says Dr. Siegal.

As former SHM President Mary Jo Gorman states in SHM’s letter of support for the Senate’s Health Partnership Act: “Many hospitalist programs exist to manage the burgeoning population of uninsured and underinsured patients who require hospitalization. These patients are more likely to delay seeking care until their illnesses deteriorate to the point that they need emergency care. In many communities, hospitalists have become the safety net for this vulnerable patient population.”

For further information about federal legislation for improved access and to see if your representatives are cosponsors, visit SHM’s Legislative Action Center at http://capwiz.com/hospitalmedicine/home/. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

The latest estimates from the National Coalition on Health Care (www.nchc.org/facts/coverage.shtml) show that 46 million Americans—nearly 16% of the population—have no health insurance, and those numbers are increasing. The federal government has been flirting with addressing this growing problem for years, but 2007 may be the turning point, when key legislation may help turn the rising tide of uninsured and underinsured patients.

“A couple of things create a more favorable milieu for this,” explains Eric Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis., and chair of SHM’s Public Policy Committee. “The first is that Massachusetts did it on their own—states are no longer waiting for Congress to do something. The second is that, with every passing year, there’s increased pressure to do something.”

Regardless of why this is happening now, some promising legislation has been introduced in Congress that may provide the beginnings of a solution.

The Health Partnership Act

Perhaps the most promising legislation on healthcare access is an innovative, bipartisan, bicameral effort known as the Health Partnership Act, which proposes a federal-state partnership to address the issue.

Identical bills have been introduced in each house. The Health Partnership Act (S. 325) was introduced in the Senate by Jeff Bingaman (D-N.M.) and George Voinovich (R-Ohio), and the Health Partnership Act through Creative Federalism (HR 506) was introduced in the House by Tammy Baldwin (D-Wis.), Tom Price (R-Ga.), and John Tierney (D-Mass.). Similar legislation was introduced by some of these same parties in the last Congress; though the bill died before action was taken, it was immediately reintroduced in the new Congress this January.

If enacted, the Health Partnership Act would give state and local governments the opportunity to implement their own solutions for providing coverage to uninsured populations, allowing them to address the unique needs that exist within their boundaries. Interested states, groups of states, or even parts of states would apply for five-year federal grants by submitting proposals that demonstrate how their plans would reduce the number of uninsured and improve healthcare quality. Each plan would include information on the appropriate use of information technology to improve the availability of evidence-based medical and outcomes data to providers and patients.

The act would establish a new bipartisan State Health Innovation Commission (SHIC), which would be part of the Department of Health and Human Services. This commission would review the state proposals and submit to Congress a list of recommended applications. It would also work with an established organization—possibly the Institute of Medicine—to develop performance measures and goals regarding coverage, quality, and cost of state programs.

Participating states would eventually report their progress to the SHIC, which would then report to Congress on whether each state was meeting the goals of the act and would then recommend further action.

Giving individual states the flexibility to create their own programs could generate new ideas and would ultimately reveal which programs work best. “We’re not expecting states to hit the ball out of the park the first time, but it’s a start,” says Dr. Siegal. “It’s a step in the right direction.”

SHM supports the Health Partnership Act and has sent a letter of support to Senate sponsors. “This [legislation] may or may not be the most expedient way to get it done,” says Dr. Siegal. “But SHM supports this legislation and is currently drafting a letter of support for the House version.”

The Healthy Americans Act

Another, more comprehensive, bill was introduced in the Senate by Ron Wyden (D-Ore.) in December 2006.

The Healthy Americans Act would require businesses to replace their current health benefits with an increase in wages equal to the amount spent on health insurance premiums. It would require all employees to use these increased wages to purchase their own health plans and would provide subsidies to low-income workers to help pay their premiums.

Those employers not currently providing any health benefits would be required to begin making phased-in “Employer Shared Responsibility Payments,” which would be used to ensure that everyone is able to afford their health plans by funding premium reductions.

Wyden’s bill would have each state establish a Health Help Agency to educate residents about private health plans, to administer enrollment, and to assist income-eligible enrollees with sliding scale premium reductions. These agencies would be funded by the federal government and insurance companies.

Finally, insurance companies would be required to cover every individual who chooses to enroll and would not be allowed to raise prices or deny coverage if individuals are sick.

Some State-Level Solutions

Some states—Massachusetts, for one—have already taken action, implementing their own innovative policies and programs to expand coverage for their populations. Maine, Massachusetts, and Vermont have instituted comprehensive healthcare reform; Arkansas, Montana, New Mexico, Oklahoma, Rhode Island, Tennessee, and Utah have all implemented some form of public-private partnerships; and Illinois and Pennsylvania have initiatives that cover all children.

Maine, Massachusetts, and Vermont all use Medicaid funds to partially subsidize healthcare coverage for families with annual incomes as high as $53,000.

For details on all current state initiatives for healthcare coverage, download the report “State of the States 2007: Building Hope, Raising Expectations” from the Web site of the State Coverage Initiatives at www.statecoverage.net.

Why Hospitalists Should Care

Providing healthcare coverage to the uninsured is one of SHM’s public policy priorities. “There really is a crisis out there, and hospitalists are on the front line of it every day,” says Dr. Siegal.

As former SHM President Mary Jo Gorman states in SHM’s letter of support for the Senate’s Health Partnership Act: “Many hospitalist programs exist to manage the burgeoning population of uninsured and underinsured patients who require hospitalization. These patients are more likely to delay seeking care until their illnesses deteriorate to the point that they need emergency care. In many communities, hospitalists have become the safety net for this vulnerable patient population.”

For further information about federal legislation for improved access and to see if your representatives are cosponsors, visit SHM’s Legislative Action Center at http://capwiz.com/hospitalmedicine/home/. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

The latest estimates from the National Coalition on Health Care (www.nchc.org/facts/coverage.shtml) show that 46 million Americans—nearly 16% of the population—have no health insurance, and those numbers are increasing. The federal government has been flirting with addressing this growing problem for years, but 2007 may be the turning point, when key legislation may help turn the rising tide of uninsured and underinsured patients.

“A couple of things create a more favorable milieu for this,” explains Eric Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis., and chair of SHM’s Public Policy Committee. “The first is that Massachusetts did it on their own—states are no longer waiting for Congress to do something. The second is that, with every passing year, there’s increased pressure to do something.”

Regardless of why this is happening now, some promising legislation has been introduced in Congress that may provide the beginnings of a solution.

The Health Partnership Act

Perhaps the most promising legislation on healthcare access is an innovative, bipartisan, bicameral effort known as the Health Partnership Act, which proposes a federal-state partnership to address the issue.

Identical bills have been introduced in each house. The Health Partnership Act (S. 325) was introduced in the Senate by Jeff Bingaman (D-N.M.) and George Voinovich (R-Ohio), and the Health Partnership Act through Creative Federalism (HR 506) was introduced in the House by Tammy Baldwin (D-Wis.), Tom Price (R-Ga.), and John Tierney (D-Mass.). Similar legislation was introduced by some of these same parties in the last Congress; though the bill died before action was taken, it was immediately reintroduced in the new Congress this January.

If enacted, the Health Partnership Act would give state and local governments the opportunity to implement their own solutions for providing coverage to uninsured populations, allowing them to address the unique needs that exist within their boundaries. Interested states, groups of states, or even parts of states would apply for five-year federal grants by submitting proposals that demonstrate how their plans would reduce the number of uninsured and improve healthcare quality. Each plan would include information on the appropriate use of information technology to improve the availability of evidence-based medical and outcomes data to providers and patients.

The act would establish a new bipartisan State Health Innovation Commission (SHIC), which would be part of the Department of Health and Human Services. This commission would review the state proposals and submit to Congress a list of recommended applications. It would also work with an established organization—possibly the Institute of Medicine—to develop performance measures and goals regarding coverage, quality, and cost of state programs.

Participating states would eventually report their progress to the SHIC, which would then report to Congress on whether each state was meeting the goals of the act and would then recommend further action.

Giving individual states the flexibility to create their own programs could generate new ideas and would ultimately reveal which programs work best. “We’re not expecting states to hit the ball out of the park the first time, but it’s a start,” says Dr. Siegal. “It’s a step in the right direction.”

SHM supports the Health Partnership Act and has sent a letter of support to Senate sponsors. “This [legislation] may or may not be the most expedient way to get it done,” says Dr. Siegal. “But SHM supports this legislation and is currently drafting a letter of support for the House version.”

The Healthy Americans Act

Another, more comprehensive, bill was introduced in the Senate by Ron Wyden (D-Ore.) in December 2006.

The Healthy Americans Act would require businesses to replace their current health benefits with an increase in wages equal to the amount spent on health insurance premiums. It would require all employees to use these increased wages to purchase their own health plans and would provide subsidies to low-income workers to help pay their premiums.

Those employers not currently providing any health benefits would be required to begin making phased-in “Employer Shared Responsibility Payments,” which would be used to ensure that everyone is able to afford their health plans by funding premium reductions.

Wyden’s bill would have each state establish a Health Help Agency to educate residents about private health plans, to administer enrollment, and to assist income-eligible enrollees with sliding scale premium reductions. These agencies would be funded by the federal government and insurance companies.

Finally, insurance companies would be required to cover every individual who chooses to enroll and would not be allowed to raise prices or deny coverage if individuals are sick.

Some State-Level Solutions

Some states—Massachusetts, for one—have already taken action, implementing their own innovative policies and programs to expand coverage for their populations. Maine, Massachusetts, and Vermont have instituted comprehensive healthcare reform; Arkansas, Montana, New Mexico, Oklahoma, Rhode Island, Tennessee, and Utah have all implemented some form of public-private partnerships; and Illinois and Pennsylvania have initiatives that cover all children.

Maine, Massachusetts, and Vermont all use Medicaid funds to partially subsidize healthcare coverage for families with annual incomes as high as $53,000.

For details on all current state initiatives for healthcare coverage, download the report “State of the States 2007: Building Hope, Raising Expectations” from the Web site of the State Coverage Initiatives at www.statecoverage.net.

Why Hospitalists Should Care

Providing healthcare coverage to the uninsured is one of SHM’s public policy priorities. “There really is a crisis out there, and hospitalists are on the front line of it every day,” says Dr. Siegal.

As former SHM President Mary Jo Gorman states in SHM’s letter of support for the Senate’s Health Partnership Act: “Many hospitalist programs exist to manage the burgeoning population of uninsured and underinsured patients who require hospitalization. These patients are more likely to delay seeking care until their illnesses deteriorate to the point that they need emergency care. In many communities, hospitalists have become the safety net for this vulnerable patient population.”

For further information about federal legislation for improved access and to see if your representatives are cosponsors, visit SHM’s Legislative Action Center at http://capwiz.com/hospitalmedicine/home/. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

At the 2006 SHM Annual Meeting Geriatrics Special Interest Forum, participants asked, “Can we create an area on the SHM Web site focused on our unique interests and needs?” Last month, SHM answered with a resounding “Yes!” as we launched the Geriatrics Special Interest Group on www.hospitalmedicine.org.

The SHM Geriatrics Special Interest Group provides a portal for SHM members to access relevant, timely information about and resources for geriatric medicine. The Community Forums provide a mechanism for participants to communicate with each other about issues in geriatric medicine and other areas of interest. In particular, the Geriatrics Special Interest Group allows users to post information about training and career development opportunities, professional meetings and forums, and funding opportunities. Users can access a wealth of geriatric-medicine resources, including breaking medical news, clinical and quality improvement tools, key publications, and archived SHM Annual Meeting presentations. The Geriatrics Special Interest Group will serve as a template for future member-requested special interest groups, including palliative care, pediatrics, and others.

The Geriatrics Special Interest Group was developed by SHM members, other experts from the community of geriatric medicine, and a team of SHM staffers. SHM member Melissa Mattison, MD, (Beth Israel Deaconess) serves as medical editor for the site and helped shape its vision, along with members Param Dedhia, MD, (Johns Hopkins, Bayview) and Jason Stein, MD (Emory University). The group also benefited from reviews and contributions made by John Degelau, MD, at HealthPartners Medical Group, Gavin W. Hougham, MD, PhD, at The John A. Hartford Foundation, Nancy Lundebjerg, MPA, and Jane Potter, MD, at the American Geriatrics Society, Odette van der Willik at the American Federation for Aging Research, and Paula M. Podrazik, MD, at the Case Management Society of America. The internal SHM development team was led by Shannon Roach and included Bruce Hanson, Travis Kamps, and Tina Budnitz.

To view the Geriatrics Special Interest Group, go to SHM’s Web site or type the address into your browser: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=12369.

We hope SHM members will utilize the Geriatrics Special Interest Group to share ideas and resources, to network, and to improve inpatient geriatric medicine. Let us know if the site meets your needs by sending your comments and suggestions to Shannon Roach at sroach@hospitalmedicine.org. Have an idea for another special interest group? E-mail us that suggestion, too.

SHM: BEHIND THE SCENES

Education and quality improvement: Reflections of a New Staff Member

By Kristin Beck

It’s nice to come to work every day and focus on education and quality improvement. Ensuring that hospitalists have the most up to date information as well as support and encouragement for implementing positive change are good reasons for leaving the house in the morning.

Only three weeks into my role as senior project manager, I have had the sincere pleasure of being involved with updating quality improvement resource rooms (common Web site areas that house tools for implementing quality improvement programs) by initiating a grant-supported program for examining observation units as they relate to treating the number one reason people are hospitalized. I have also accomplished writing and submitting a grant for the Quality Improvement Pre-Course, as well as, working with a committee that looks at patient quality care and projects to enhance it.

Our work here focuses on examining what has been done, how we can improve it, and how we can institute best practices. Not bad for three weeks’ work!

Conversations in our department focus on whether members get what they need and want. People meet regularly to discuss how we can refine and improve the services we offer. Strategies for securing funding and developing programs are reviewed, not for this calendar or fiscal year but for years to come. In one of my final interviews for this job, I was reminded that we don’t deliver here—we over-deliver. Looking through The Hospitalist, titles that stand out include the words unforgettable, safety, expert, leader, admire, and smart.

When people ask what I do in my new job, I tell them that hospital medicine looks at the total experience of being a doctor. It focuses not only on medical care but also on the complete experience of being a working professional: the arts of research, negotiation, best practices, team-focused care, conflict resolution, and systems change. I explain that we do life-saving work, for it is far more than the practice of just day-to-day medicine that improves all of our lives. I tell people that it is work that makes sense.

When you come to work every day and are surrounded by a dynamic, positive energy, the work you produce is likely to mirror the hospital medicine movement: You will reflect, revise, and grow stronger. Sincere, well-planned initiatives are infectious. Continually participating in an environment that asks the questions, “Where can we take this?” and “What can we do better?” is a pretty good reason to get out of bed in the morning.

Beck is the senior project manager at SHM.

VTE Prevention Collaborative off to a Great Start

The VTE Prevention Collaborative (VTE PC) is the latest SHM initiative to support hospitalist-led efforts to reduce the incidence of preventable, hospital-acquired VTE. Launched in January 2007, the program offers individualized assistance to hospitalists who want to take the lead on this critical quality and patient safety issue.

Hospital-Acquired Venous Thromboembolism

The problem of hospital-acquired VTE is huge. More than 2 million Americans suffer from VTE each year. Most hospitalized patients have at least one risk factor for VTE. In a large registry trial capturing more than 5,451 patients at 183 sites in a six-month period, 50% (2,726) developed their VTE during hospitalization.1 A 400-bed hospital with an average rate of VTE prophylaxis can expect that 200 patients will suffer from hospital-acquired VTE each year; around half of these cases are potentially preventable.1,2

The good news is that effective and safe measures to prevent hospital-acquired VTE exist. Pharmacologic prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and pulmonary embolism (PE) by 50%-65%.3, 4-11 Prevention of DVT also prevents PE and fatalities from PE. The chief concern of prophylaxis is bleeding, but bleeding risk secondary to pharmacologic prophylaxis is a rare event, as is shown in abundant data from meta-analyses and placebo-controlled, randomized controlled trials.3,4

click for large version

Close the Gap

Reliably preventing VTE in the hospital is inherently complex. VTE risk and bleeding risks vary within patient populations, and these risks may change for an individual patient several times in the course of the hospital stay. Weight, age, renal function, medication changes, and recent or impending invasive interventions may all influence decisions about the best VTE prevention options. Transitions across care providers and locations translate into multiple opportunities for breakdown in the delivery of optimal VTE prophylaxis. Thoughtful, evidence-based protocols, multidisciplinary system changes, and comprehensive educational efforts are required to achieve optimal VTE prophylaxis in the complex hospital setting.

How the VTE PC Can Help

The VTE PC program builds on and complements the VTE prevention materials and educational resources that SHM has produced in recent years. “Our Quality Improvement Resource Rooms have the information and resources needed to tackle a number of key quality issues,” says SHM CEO Larry Wellikson. “The VTE PC project takes this one step further by providing individualized mentorship. SHM is committed to supporting these forward-thinking, unique strategies that will allow hospitalists to lead their hospitals into a better future.”

VTE PC participants can choose the type of support that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.

The mentoring program presents a perfect option for individuals interested in ongoing support for their planned or active VTE prevention projects. Through the project, SHM mentors with VTE and QI experts who work with participants during eight telephone calls scheduled throughout a yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. Instruction and assistance are tailored to participant needs and commonly focus on:

• Working with medical center administration;
• Using practical methods to assess institutional performance in VTE prophylaxis;
• Identifying and tracking patients with hospital-acquired VTE;
• Constructing a VTE risk-assessment model and integrating it into workflow, order sets, and protocols;
• Enhancing selection of appropriate prophylaxis by linking the VTE risk assessment to a corresponding menu of proven options; and
• Bolstering your chances of success by utilizing high-reliability design features and effective implementation techniques.

The on-site consultation program is a good option for individuals interested in securing expert evaluation and input on a VTE prevention program but who don’t need ongoing support. Through the on-site consultation program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits are especially helpful to participants with existing VTE prevention programs that they wish to expand or improve upon.

The consultation visits feature a structured evaluation of the site’s strengths and resources, barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation-visit activities vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools. Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation.

Collaborative Members

SHM membership has responded enthusiastically to the VTE PC project. Early enrollees have a wide range of experience with VTE prevention and QI in general. Some fill QI leadership roles in their hospitals or hospital medicine groups; for others, the VTE prevention project is their first experience leading a QI effort. Enrollees represent a range of hospital types (academic centers, community teaching hospitals, community hospitals) and sizes (staffed beds range from 135 to 650) and are located in every U.S. geographic region in multiple hospital systems.

Several participants represent hospitals where VTE prevention programs have been implemented, while most have active projects in which no intervention has yet been implemented; a handful are still in the planning/initial exploration phase of work. Nearly half of the enrolled sites have a history of failed QI efforts in VTE prevention.

Many enrollees are looking to their VTE prevention efforts as a means of positioning their hospital medicine group as a local QI force. “This is the first large project the hospitalist group has undertaken since getting up and running,” reports one attendee. “I would really like to make a positive impact on patient care and lay the groundwork with this project that would allow us to be successful with future undertakings.”

Applying to the Programs

Participation in both the mentoring and on-site consultation programs is open to hospitalists who lead proposed or active VTE prevention projects. Participation is free, but enrollment is limited, so interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.

Direct your questions about VTE Prevention Collaborative programs to vtepc@hospitalmedicine.org.

Bibliography

1. Goldhaber SZ, Tapson VF; DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004 Jan;93(2):259-262.
2. Maynard G. Workbook for Improvement: optimize prevention of venous thromboembolism at your medical center [SHM Web site, VTE Quality Improvement Resource Room]. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms&Template=/CM/ContentDisplay.cfm&ContentID=6092. Last accessed March 19, 2007.
3. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Review. Comment in Chest. 2005 Jun;127(6):2297-2298.
4. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43 [Agency for Healthcare Research and Quality Web site]. July 2001;332–346;AHRQ Publication No. 01-E058. Available at: www.ahrq.gov/clinic/ptsafety/. Last accessed March 19, 2007.
5. Belch JJ, Lowe GD, Ward AG, et al. Prevention of deep vein thrombosis in medical patients by low-dose heparin. Scott Med J. 1981 Apr;26(2):115–117.
6. Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. The Heparin Prophylaxis Study Group. Lancet. 1996 May 18;347(9021):1357–1361. Comment in: ACP J Club. 1996 Nov-Dec;125(3):64 & Lancet. 1996 Jul 20; 348(9021):205-206.
7. Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999 Sep 9;341(11):793–800.
8. Leizorovicz A, Cohen AT, Turpie AG, et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004 Aug 17;110(7):874-879.
9. Kleber FX, Witt C, Vogel G, et al. Randomized comparison of enoxaparin with unfractionated heparin for the prevention of venous thromboembolism in medical patients with heart failure or severe respiratory disease. Am Heart J. 2003 Apr;145(4):614–621.
10. Lechler E, Schramm W, Flosbach CW. The venous thrombotic risk in non-surgical patients: epidemiological data and efficacy/safety profile of a low-molecular-weight heparin (enoxaparin). The Prime Study Group. Haemostasis. 1996;26(Suppl):49–56.
11. Cohen AT, Davidson BL, Gallus AS, et al. Fondaparinux for the prevention of VTE in acutely ill medical patients (abstract 42). Blood. 2003;102:15a.

Awards Ceremony Preview

SHM created the Awards of Excellence program to honor members whose contributions to the hospital medicine movement deserve acknowledgment and respect. Award winners will receive complimentary registration and paid airfare to SHM’s Annual Meeting, which is being held this month in Dallas and will be presented during the President’s luncheon. Any physician member whose focus is the general medical care of hospitalized patients is eligible for nomination of the four awards. Award winners have been selected for the following categories: Clinical Excellence, Excellence in Teaching, Outstanding Service, and Research.

The SHM Award for Clinical Excellence will be presented to an individual for recognition of exemplary clinical service in hospital medicine. The Awards Committee has evaluated the candidates according to their outstanding contributions to patient care, their advancement of clinical knowledge, including their leadership and professionalism in medicine, as well as personal excellence in practice management.

The SHM Award for Excellence in Teaching is presented in recognition of outstanding teaching and mentorship in hospital medicine, most specifically within the academic and community practice settings. Consideration was given to those nominees who demonstrated outstanding teaching ability and who served as role models and mentored other hospitalists, residents, medical students, or other healthcare professionals.

The SHM Award for Outstanding Service in Hospital Medicine is presented in recognition of exceptional service to the discipline of hospital medicine. The winning candidate has displayed exemplary organizational and leadership activities within organized medicine and has shown contributing support in public policy.

The SHM Excellence in Research Award is presented in recognition of outstanding achievement by a researcher in the discipline of hospital medicine. The candidate selected presented peer-reviewed publications and continued education with additional research and training that provided for both intra- and extramural funding for research.

For additional information regarding SHM’s Awards Program, please e-mail awards@hospitalmedicine.org. TH

At the 2006 SHM Annual Meeting Geriatrics Special Interest Forum, participants asked, “Can we create an area on the SHM Web site focused on our unique interests and needs?” Last month, SHM answered with a resounding “Yes!” as we launched the Geriatrics Special Interest Group on www.hospitalmedicine.org.

The SHM Geriatrics Special Interest Group provides a portal for SHM members to access relevant, timely information about and resources for geriatric medicine. The Community Forums provide a mechanism for participants to communicate with each other about issues in geriatric medicine and other areas of interest. In particular, the Geriatrics Special Interest Group allows users to post information about training and career development opportunities, professional meetings and forums, and funding opportunities. Users can access a wealth of geriatric-medicine resources, including breaking medical news, clinical and quality improvement tools, key publications, and archived SHM Annual Meeting presentations. The Geriatrics Special Interest Group will serve as a template for future member-requested special interest groups, including palliative care, pediatrics, and others.

The Geriatrics Special Interest Group was developed by SHM members, other experts from the community of geriatric medicine, and a team of SHM staffers. SHM member Melissa Mattison, MD, (Beth Israel Deaconess) serves as medical editor for the site and helped shape its vision, along with members Param Dedhia, MD, (Johns Hopkins, Bayview) and Jason Stein, MD (Emory University). The group also benefited from reviews and contributions made by John Degelau, MD, at HealthPartners Medical Group, Gavin W. Hougham, MD, PhD, at The John A. Hartford Foundation, Nancy Lundebjerg, MPA, and Jane Potter, MD, at the American Geriatrics Society, Odette van der Willik at the American Federation for Aging Research, and Paula M. Podrazik, MD, at the Case Management Society of America. The internal SHM development team was led by Shannon Roach and included Bruce Hanson, Travis Kamps, and Tina Budnitz.

To view the Geriatrics Special Interest Group, go to SHM’s Web site or type the address into your browser: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=12369.

We hope SHM members will utilize the Geriatrics Special Interest Group to share ideas and resources, to network, and to improve inpatient geriatric medicine. Let us know if the site meets your needs by sending your comments and suggestions to Shannon Roach at sroach@hospitalmedicine.org. Have an idea for another special interest group? E-mail us that suggestion, too.

SHM: BEHIND THE SCENES

Education and quality improvement: Reflections of a New Staff Member

By Kristin Beck

It’s nice to come to work every day and focus on education and quality improvement. Ensuring that hospitalists have the most up to date information as well as support and encouragement for implementing positive change are good reasons for leaving the house in the morning.

Only three weeks into my role as senior project manager, I have had the sincere pleasure of being involved with updating quality improvement resource rooms (common Web site areas that house tools for implementing quality improvement programs) by initiating a grant-supported program for examining observation units as they relate to treating the number one reason people are hospitalized. I have also accomplished writing and submitting a grant for the Quality Improvement Pre-Course, as well as, working with a committee that looks at patient quality care and projects to enhance it.

Our work here focuses on examining what has been done, how we can improve it, and how we can institute best practices. Not bad for three weeks’ work!

Conversations in our department focus on whether members get what they need and want. People meet regularly to discuss how we can refine and improve the services we offer. Strategies for securing funding and developing programs are reviewed, not for this calendar or fiscal year but for years to come. In one of my final interviews for this job, I was reminded that we don’t deliver here—we over-deliver. Looking through The Hospitalist, titles that stand out include the words unforgettable, safety, expert, leader, admire, and smart.

When people ask what I do in my new job, I tell them that hospital medicine looks at the total experience of being a doctor. It focuses not only on medical care but also on the complete experience of being a working professional: the arts of research, negotiation, best practices, team-focused care, conflict resolution, and systems change. I explain that we do life-saving work, for it is far more than the practice of just day-to-day medicine that improves all of our lives. I tell people that it is work that makes sense.

When you come to work every day and are surrounded by a dynamic, positive energy, the work you produce is likely to mirror the hospital medicine movement: You will reflect, revise, and grow stronger. Sincere, well-planned initiatives are infectious. Continually participating in an environment that asks the questions, “Where can we take this?” and “What can we do better?” is a pretty good reason to get out of bed in the morning.

Beck is the senior project manager at SHM.

VTE Prevention Collaborative off to a Great Start

The VTE Prevention Collaborative (VTE PC) is the latest SHM initiative to support hospitalist-led efforts to reduce the incidence of preventable, hospital-acquired VTE. Launched in January 2007, the program offers individualized assistance to hospitalists who want to take the lead on this critical quality and patient safety issue.

Hospital-Acquired Venous Thromboembolism

The problem of hospital-acquired VTE is huge. More than 2 million Americans suffer from VTE each year. Most hospitalized patients have at least one risk factor for VTE. In a large registry trial capturing more than 5,451 patients at 183 sites in a six-month period, 50% (2,726) developed their VTE during hospitalization.1 A 400-bed hospital with an average rate of VTE prophylaxis can expect that 200 patients will suffer from hospital-acquired VTE each year; around half of these cases are potentially preventable.1,2

The good news is that effective and safe measures to prevent hospital-acquired VTE exist. Pharmacologic prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and pulmonary embolism (PE) by 50%-65%.3, 4-11 Prevention of DVT also prevents PE and fatalities from PE. The chief concern of prophylaxis is bleeding, but bleeding risk secondary to pharmacologic prophylaxis is a rare event, as is shown in abundant data from meta-analyses and placebo-controlled, randomized controlled trials.3,4

click for large version

Close the Gap

Reliably preventing VTE in the hospital is inherently complex. VTE risk and bleeding risks vary within patient populations, and these risks may change for an individual patient several times in the course of the hospital stay. Weight, age, renal function, medication changes, and recent or impending invasive interventions may all influence decisions about the best VTE prevention options. Transitions across care providers and locations translate into multiple opportunities for breakdown in the delivery of optimal VTE prophylaxis. Thoughtful, evidence-based protocols, multidisciplinary system changes, and comprehensive educational efforts are required to achieve optimal VTE prophylaxis in the complex hospital setting.

How the VTE PC Can Help

The VTE PC program builds on and complements the VTE prevention materials and educational resources that SHM has produced in recent years. “Our Quality Improvement Resource Rooms have the information and resources needed to tackle a number of key quality issues,” says SHM CEO Larry Wellikson. “The VTE PC project takes this one step further by providing individualized mentorship. SHM is committed to supporting these forward-thinking, unique strategies that will allow hospitalists to lead their hospitals into a better future.”

VTE PC participants can choose the type of support that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.

The mentoring program presents a perfect option for individuals interested in ongoing support for their planned or active VTE prevention projects. Through the project, SHM mentors with VTE and QI experts who work with participants during eight telephone calls scheduled throughout a yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. Instruction and assistance are tailored to participant needs and commonly focus on:

• Working with medical center administration;
• Using practical methods to assess institutional performance in VTE prophylaxis;
• Identifying and tracking patients with hospital-acquired VTE;
• Constructing a VTE risk-assessment model and integrating it into workflow, order sets, and protocols;
• Enhancing selection of appropriate prophylaxis by linking the VTE risk assessment to a corresponding menu of proven options; and
• Bolstering your chances of success by utilizing high-reliability design features and effective implementation techniques.

The on-site consultation program is a good option for individuals interested in securing expert evaluation and input on a VTE prevention program but who don’t need ongoing support. Through the on-site consultation program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits are especially helpful to participants with existing VTE prevention programs that they wish to expand or improve upon.

The consultation visits feature a structured evaluation of the site’s strengths and resources, barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation-visit activities vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools. Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation.

Collaborative Members

SHM membership has responded enthusiastically to the VTE PC project. Early enrollees have a wide range of experience with VTE prevention and QI in general. Some fill QI leadership roles in their hospitals or hospital medicine groups; for others, the VTE prevention project is their first experience leading a QI effort. Enrollees represent a range of hospital types (academic centers, community teaching hospitals, community hospitals) and sizes (staffed beds range from 135 to 650) and are located in every U.S. geographic region in multiple hospital systems.

Several participants represent hospitals where VTE prevention programs have been implemented, while most have active projects in which no intervention has yet been implemented; a handful are still in the planning/initial exploration phase of work. Nearly half of the enrolled sites have a history of failed QI efforts in VTE prevention.

Many enrollees are looking to their VTE prevention efforts as a means of positioning their hospital medicine group as a local QI force. “This is the first large project the hospitalist group has undertaken since getting up and running,” reports one attendee. “I would really like to make a positive impact on patient care and lay the groundwork with this project that would allow us to be successful with future undertakings.”

Applying to the Programs

Participation in both the mentoring and on-site consultation programs is open to hospitalists who lead proposed or active VTE prevention projects. Participation is free, but enrollment is limited, so interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.

Direct your questions about VTE Prevention Collaborative programs to vtepc@hospitalmedicine.org.

Bibliography

1. Goldhaber SZ, Tapson VF; DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004 Jan;93(2):259-262.
2. Maynard G. Workbook for Improvement: optimize prevention of venous thromboembolism at your medical center [SHM Web site, VTE Quality Improvement Resource Room]. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms&Template=/CM/ContentDisplay.cfm&ContentID=6092. Last accessed March 19, 2007.
3. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Review. Comment in Chest. 2005 Jun;127(6):2297-2298.
4. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43 [Agency for Healthcare Research and Quality Web site]. July 2001;332–346;AHRQ Publication No. 01-E058. Available at: www.ahrq.gov/clinic/ptsafety/. Last accessed March 19, 2007.
5. Belch JJ, Lowe GD, Ward AG, et al. Prevention of deep vein thrombosis in medical patients by low-dose heparin. Scott Med J. 1981 Apr;26(2):115–117.
6. Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. The Heparin Prophylaxis Study Group. Lancet. 1996 May 18;347(9021):1357–1361. Comment in: ACP J Club. 1996 Nov-Dec;125(3):64 & Lancet. 1996 Jul 20; 348(9021):205-206.
7. Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999 Sep 9;341(11):793–800.
8. Leizorovicz A, Cohen AT, Turpie AG, et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004 Aug 17;110(7):874-879.
9. Kleber FX, Witt C, Vogel G, et al. Randomized comparison of enoxaparin with unfractionated heparin for the prevention of venous thromboembolism in medical patients with heart failure or severe respiratory disease. Am Heart J. 2003 Apr;145(4):614–621.
10. Lechler E, Schramm W, Flosbach CW. The venous thrombotic risk in non-surgical patients: epidemiological data and efficacy/safety profile of a low-molecular-weight heparin (enoxaparin). The Prime Study Group. Haemostasis. 1996;26(Suppl):49–56.
11. Cohen AT, Davidson BL, Gallus AS, et al. Fondaparinux for the prevention of VTE in acutely ill medical patients (abstract 42). Blood. 2003;102:15a.

Awards Ceremony Preview

SHM created the Awards of Excellence program to honor members whose contributions to the hospital medicine movement deserve acknowledgment and respect. Award winners will receive complimentary registration and paid airfare to SHM’s Annual Meeting, which is being held this month in Dallas and will be presented during the President’s luncheon. Any physician member whose focus is the general medical care of hospitalized patients is eligible for nomination of the four awards. Award winners have been selected for the following categories: Clinical Excellence, Excellence in Teaching, Outstanding Service, and Research.

The SHM Award for Clinical Excellence will be presented to an individual for recognition of exemplary clinical service in hospital medicine. The Awards Committee has evaluated the candidates according to their outstanding contributions to patient care, their advancement of clinical knowledge, including their leadership and professionalism in medicine, as well as personal excellence in practice management.

The SHM Award for Excellence in Teaching is presented in recognition of outstanding teaching and mentorship in hospital medicine, most specifically within the academic and community practice settings. Consideration was given to those nominees who demonstrated outstanding teaching ability and who served as role models and mentored other hospitalists, residents, medical students, or other healthcare professionals.

The SHM Award for Outstanding Service in Hospital Medicine is presented in recognition of exceptional service to the discipline of hospital medicine. The winning candidate has displayed exemplary organizational and leadership activities within organized medicine and has shown contributing support in public policy.

The SHM Excellence in Research Award is presented in recognition of outstanding achievement by a researcher in the discipline of hospital medicine. The candidate selected presented peer-reviewed publications and continued education with additional research and training that provided for both intra- and extramural funding for research.

For additional information regarding SHM’s Awards Program, please e-mail awards@hospitalmedicine.org. TH

At the 2006 SHM Annual Meeting Geriatrics Special Interest Forum, participants asked, “Can we create an area on the SHM Web site focused on our unique interests and needs?” Last month, SHM answered with a resounding “Yes!” as we launched the Geriatrics Special Interest Group on www.hospitalmedicine.org.

The SHM Geriatrics Special Interest Group provides a portal for SHM members to access relevant, timely information about and resources for geriatric medicine. The Community Forums provide a mechanism for participants to communicate with each other about issues in geriatric medicine and other areas of interest. In particular, the Geriatrics Special Interest Group allows users to post information about training and career development opportunities, professional meetings and forums, and funding opportunities. Users can access a wealth of geriatric-medicine resources, including breaking medical news, clinical and quality improvement tools, key publications, and archived SHM Annual Meeting presentations. The Geriatrics Special Interest Group will serve as a template for future member-requested special interest groups, including palliative care, pediatrics, and others.

The Geriatrics Special Interest Group was developed by SHM members, other experts from the community of geriatric medicine, and a team of SHM staffers. SHM member Melissa Mattison, MD, (Beth Israel Deaconess) serves as medical editor for the site and helped shape its vision, along with members Param Dedhia, MD, (Johns Hopkins, Bayview) and Jason Stein, MD (Emory University). The group also benefited from reviews and contributions made by John Degelau, MD, at HealthPartners Medical Group, Gavin W. Hougham, MD, PhD, at The John A. Hartford Foundation, Nancy Lundebjerg, MPA, and Jane Potter, MD, at the American Geriatrics Society, Odette van der Willik at the American Federation for Aging Research, and Paula M. Podrazik, MD, at the Case Management Society of America. The internal SHM development team was led by Shannon Roach and included Bruce Hanson, Travis Kamps, and Tina Budnitz.

To view the Geriatrics Special Interest Group, go to SHM’s Web site or type the address into your browser: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=12369.

We hope SHM members will utilize the Geriatrics Special Interest Group to share ideas and resources, to network, and to improve inpatient geriatric medicine. Let us know if the site meets your needs by sending your comments and suggestions to Shannon Roach at sroach@hospitalmedicine.org. Have an idea for another special interest group? E-mail us that suggestion, too.

SHM: BEHIND THE SCENES

Education and quality improvement: Reflections of a New Staff Member

By Kristin Beck

It’s nice to come to work every day and focus on education and quality improvement. Ensuring that hospitalists have the most up to date information as well as support and encouragement for implementing positive change are good reasons for leaving the house in the morning.

Only three weeks into my role as senior project manager, I have had the sincere pleasure of being involved with updating quality improvement resource rooms (common Web site areas that house tools for implementing quality improvement programs) by initiating a grant-supported program for examining observation units as they relate to treating the number one reason people are hospitalized. I have also accomplished writing and submitting a grant for the Quality Improvement Pre-Course, as well as, working with a committee that looks at patient quality care and projects to enhance it.

Our work here focuses on examining what has been done, how we can improve it, and how we can institute best practices. Not bad for three weeks’ work!

Conversations in our department focus on whether members get what they need and want. People meet regularly to discuss how we can refine and improve the services we offer. Strategies for securing funding and developing programs are reviewed, not for this calendar or fiscal year but for years to come. In one of my final interviews for this job, I was reminded that we don’t deliver here—we over-deliver. Looking through The Hospitalist, titles that stand out include the words unforgettable, safety, expert, leader, admire, and smart.

When people ask what I do in my new job, I tell them that hospital medicine looks at the total experience of being a doctor. It focuses not only on medical care but also on the complete experience of being a working professional: the arts of research, negotiation, best practices, team-focused care, conflict resolution, and systems change. I explain that we do life-saving work, for it is far more than the practice of just day-to-day medicine that improves all of our lives. I tell people that it is work that makes sense.

When you come to work every day and are surrounded by a dynamic, positive energy, the work you produce is likely to mirror the hospital medicine movement: You will reflect, revise, and grow stronger. Sincere, well-planned initiatives are infectious. Continually participating in an environment that asks the questions, “Where can we take this?” and “What can we do better?” is a pretty good reason to get out of bed in the morning.

Beck is the senior project manager at SHM.

VTE Prevention Collaborative off to a Great Start

The VTE Prevention Collaborative (VTE PC) is the latest SHM initiative to support hospitalist-led efforts to reduce the incidence of preventable, hospital-acquired VTE. Launched in January 2007, the program offers individualized assistance to hospitalists who want to take the lead on this critical quality and patient safety issue.

Hospital-Acquired Venous Thromboembolism

The problem of hospital-acquired VTE is huge. More than 2 million Americans suffer from VTE each year. Most hospitalized patients have at least one risk factor for VTE. In a large registry trial capturing more than 5,451 patients at 183 sites in a six-month period, 50% (2,726) developed their VTE during hospitalization.1 A 400-bed hospital with an average rate of VTE prophylaxis can expect that 200 patients will suffer from hospital-acquired VTE each year; around half of these cases are potentially preventable.1,2

The good news is that effective and safe measures to prevent hospital-acquired VTE exist. Pharmacologic prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and pulmonary embolism (PE) by 50%-65%.3, 4-11 Prevention of DVT also prevents PE and fatalities from PE. The chief concern of prophylaxis is bleeding, but bleeding risk secondary to pharmacologic prophylaxis is a rare event, as is shown in abundant data from meta-analyses and placebo-controlled, randomized controlled trials.3,4

click for large version

Close the Gap

Reliably preventing VTE in the hospital is inherently complex. VTE risk and bleeding risks vary within patient populations, and these risks may change for an individual patient several times in the course of the hospital stay. Weight, age, renal function, medication changes, and recent or impending invasive interventions may all influence decisions about the best VTE prevention options. Transitions across care providers and locations translate into multiple opportunities for breakdown in the delivery of optimal VTE prophylaxis. Thoughtful, evidence-based protocols, multidisciplinary system changes, and comprehensive educational efforts are required to achieve optimal VTE prophylaxis in the complex hospital setting.

How the VTE PC Can Help

The VTE PC program builds on and complements the VTE prevention materials and educational resources that SHM has produced in recent years. “Our Quality Improvement Resource Rooms have the information and resources needed to tackle a number of key quality issues,” says SHM CEO Larry Wellikson. “The VTE PC project takes this one step further by providing individualized mentorship. SHM is committed to supporting these forward-thinking, unique strategies that will allow hospitalists to lead their hospitals into a better future.”

VTE PC participants can choose the type of support that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.

The mentoring program presents a perfect option for individuals interested in ongoing support for their planned or active VTE prevention projects. Through the project, SHM mentors with VTE and QI experts who work with participants during eight telephone calls scheduled throughout a yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. Instruction and assistance are tailored to participant needs and commonly focus on:

• Working with medical center administration;
• Using practical methods to assess institutional performance in VTE prophylaxis;
• Identifying and tracking patients with hospital-acquired VTE;
• Constructing a VTE risk-assessment model and integrating it into workflow, order sets, and protocols;
• Enhancing selection of appropriate prophylaxis by linking the VTE risk assessment to a corresponding menu of proven options; and
• Bolstering your chances of success by utilizing high-reliability design features and effective implementation techniques.

The on-site consultation program is a good option for individuals interested in securing expert evaluation and input on a VTE prevention program but who don’t need ongoing support. Through the on-site consultation program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits are especially helpful to participants with existing VTE prevention programs that they wish to expand or improve upon.

The consultation visits feature a structured evaluation of the site’s strengths and resources, barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation-visit activities vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools. Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation.

Collaborative Members

SHM membership has responded enthusiastically to the VTE PC project. Early enrollees have a wide range of experience with VTE prevention and QI in general. Some fill QI leadership roles in their hospitals or hospital medicine groups; for others, the VTE prevention project is their first experience leading a QI effort. Enrollees represent a range of hospital types (academic centers, community teaching hospitals, community hospitals) and sizes (staffed beds range from 135 to 650) and are located in every U.S. geographic region in multiple hospital systems.

Several participants represent hospitals where VTE prevention programs have been implemented, while most have active projects in which no intervention has yet been implemented; a handful are still in the planning/initial exploration phase of work. Nearly half of the enrolled sites have a history of failed QI efforts in VTE prevention.

Many enrollees are looking to their VTE prevention efforts as a means of positioning their hospital medicine group as a local QI force. “This is the first large project the hospitalist group has undertaken since getting up and running,” reports one attendee. “I would really like to make a positive impact on patient care and lay the groundwork with this project that would allow us to be successful with future undertakings.”

Applying to the Programs

Participation in both the mentoring and on-site consultation programs is open to hospitalists who lead proposed or active VTE prevention projects. Participation is free, but enrollment is limited, so interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.

Direct your questions about VTE Prevention Collaborative programs to vtepc@hospitalmedicine.org.

Bibliography

1. Goldhaber SZ, Tapson VF; DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004 Jan;93(2):259-262.
2. Maynard G. Workbook for Improvement: optimize prevention of venous thromboembolism at your medical center [SHM Web site, VTE Quality Improvement Resource Room]. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms&Template=/CM/ContentDisplay.cfm&ContentID=6092. Last accessed March 19, 2007.
3. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Review. Comment in Chest. 2005 Jun;127(6):2297-2298.
4. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43 [Agency for Healthcare Research and Quality Web site]. July 2001;332–346;AHRQ Publication No. 01-E058. Available at: www.ahrq.gov/clinic/ptsafety/. Last accessed March 19, 2007.
5. Belch JJ, Lowe GD, Ward AG, et al. Prevention of deep vein thrombosis in medical patients by low-dose heparin. Scott Med J. 1981 Apr;26(2):115–117.
6. Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. The Heparin Prophylaxis Study Group. Lancet. 1996 May 18;347(9021):1357–1361. Comment in: ACP J Club. 1996 Nov-Dec;125(3):64 & Lancet. 1996 Jul 20; 348(9021):205-206.
7. Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999 Sep 9;341(11):793–800.
8. Leizorovicz A, Cohen AT, Turpie AG, et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004 Aug 17;110(7):874-879.
9. Kleber FX, Witt C, Vogel G, et al. Randomized comparison of enoxaparin with unfractionated heparin for the prevention of venous thromboembolism in medical patients with heart failure or severe respiratory disease. Am Heart J. 2003 Apr;145(4):614–621.
10. Lechler E, Schramm W, Flosbach CW. The venous thrombotic risk in non-surgical patients: epidemiological data and efficacy/safety profile of a low-molecular-weight heparin (enoxaparin). The Prime Study Group. Haemostasis. 1996;26(Suppl):49–56.
11. Cohen AT, Davidson BL, Gallus AS, et al. Fondaparinux for the prevention of VTE in acutely ill medical patients (abstract 42). Blood. 2003;102:15a.

Awards Ceremony Preview

SHM created the Awards of Excellence program to honor members whose contributions to the hospital medicine movement deserve acknowledgment and respect. Award winners will receive complimentary registration and paid airfare to SHM’s Annual Meeting, which is being held this month in Dallas and will be presented during the President’s luncheon. Any physician member whose focus is the general medical care of hospitalized patients is eligible for nomination of the four awards. Award winners have been selected for the following categories: Clinical Excellence, Excellence in Teaching, Outstanding Service, and Research.

The SHM Award for Clinical Excellence will be presented to an individual for recognition of exemplary clinical service in hospital medicine. The Awards Committee has evaluated the candidates according to their outstanding contributions to patient care, their advancement of clinical knowledge, including their leadership and professionalism in medicine, as well as personal excellence in practice management.

The SHM Award for Excellence in Teaching is presented in recognition of outstanding teaching and mentorship in hospital medicine, most specifically within the academic and community practice settings. Consideration was given to those nominees who demonstrated outstanding teaching ability and who served as role models and mentored other hospitalists, residents, medical students, or other healthcare professionals.

The SHM Award for Outstanding Service in Hospital Medicine is presented in recognition of exceptional service to the discipline of hospital medicine. The winning candidate has displayed exemplary organizational and leadership activities within organized medicine and has shown contributing support in public policy.

The SHM Excellence in Research Award is presented in recognition of outstanding achievement by a researcher in the discipline of hospital medicine. The candidate selected presented peer-reviewed publications and continued education with additional research and training that provided for both intra- and extramural funding for research.

For additional information regarding SHM’s Awards Program, please e-mail awards@hospitalmedicine.org. TH

Supplement Editors:
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Contents

The recognition of urologic disease is a primary care issue, whether we've know it or not
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Screening for urologic malignancies in primary care: Pros, cons, and recommendations
Andrew J. Stephenson, MD; Louis Kuritzky, MD; and Steven C. Campbell, MD, PhD

Benign prostatic hyperplasia: When to 'watch and wait,' when and how to treat
Albert Levy, MD, and George P. Samraj, MD

Overactive bladder: Recognition requires vigilance for symptoms
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; Christopher T. Tallman, BS; and Shari A. Page, CFNP

Erectile dysfunction: A sentinel marker for cardiovascular disease in primary care
Martin M. Miner, MD, and Louis Kuritzky, MD

Evolving issues in male hypogonadism: Evaluation, management, and related cormorbidities
Martin M. Miner, MD, and Richard Sadovsky, MD

Identifying and treating premature ejaculation: Importance of the sexual history
Richard E. Payne, MD, and Richard Sadovsky, MD

Interstitial cystitis/painful bladder syndrome: Symptom recognition is key to early identification, treatment
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; and Shari A. Page CFNP

Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key
Jeannette Potts, MD, and Richard E. Payne, MD

Supplement Editors:
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Contents

The recognition of urologic disease is a primary care issue, whether we've know it or not
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Screening for urologic malignancies in primary care: Pros, cons, and recommendations
Andrew J. Stephenson, MD; Louis Kuritzky, MD; and Steven C. Campbell, MD, PhD

Benign prostatic hyperplasia: When to 'watch and wait,' when and how to treat
Albert Levy, MD, and George P. Samraj, MD

Overactive bladder: Recognition requires vigilance for symptoms
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; Christopher T. Tallman, BS; and Shari A. Page, CFNP

Erectile dysfunction: A sentinel marker for cardiovascular disease in primary care
Martin M. Miner, MD, and Louis Kuritzky, MD

Evolving issues in male hypogonadism: Evaluation, management, and related cormorbidities
Martin M. Miner, MD, and Richard Sadovsky, MD

Identifying and treating premature ejaculation: Importance of the sexual history
Richard E. Payne, MD, and Richard Sadovsky, MD

Interstitial cystitis/painful bladder syndrome: Symptom recognition is key to early identification, treatment
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; and Shari A. Page CFNP

Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key
Jeannette Potts, MD, and Richard E. Payne, MD

Supplement Editors:
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Contents

The recognition of urologic disease is a primary care issue, whether we've know it or not
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Screening for urologic malignancies in primary care: Pros, cons, and recommendations
Andrew J. Stephenson, MD; Louis Kuritzky, MD; and Steven C. Campbell, MD, PhD

Benign prostatic hyperplasia: When to 'watch and wait,' when and how to treat
Albert Levy, MD, and George P. Samraj, MD

Overactive bladder: Recognition requires vigilance for symptoms
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; Christopher T. Tallman, BS; and Shari A. Page, CFNP

Erectile dysfunction: A sentinel marker for cardiovascular disease in primary care
Martin M. Miner, MD, and Louis Kuritzky, MD

Evolving issues in male hypogonadism: Evaluation, management, and related cormorbidities
Martin M. Miner, MD, and Richard Sadovsky, MD

Identifying and treating premature ejaculation: Importance of the sexual history
Richard E. Payne, MD, and Richard Sadovsky, MD

Interstitial cystitis/painful bladder syndrome: Symptom recognition is key to early identification, treatment
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; and Shari A. Page CFNP

Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key
Jeannette Potts, MD, and Richard E. Payne, MD

When you start work as a hospitalist, you’ll tend to immerse yourself in your new job. But you should also strive to maintain a work-life balance from the start, to guard against eventual burnout.

“It’s really work-family-self balance, because of the importance of self-care,” says Maureen Murray of Maureen Murray Associates in Pittsburgh, who provides professional training in stress management and work-life balance. “Self-care is more than just running or dieting—it’s the foundation of a balanced life.”

Areas of Self-Care

“If you don’t put yourself first, you won’t be very effective at caring for others,” says Murray. Her training program categorizes self-care into four areas:

Physical: What keeps me healthy? “Most people already know the answer to this,” says Murray. “Some form of regular activity, eating reasonably well, and getting some rest.” Mental: What energizes my mind? The answer is “something different,” according to Murray.

• Read a book or see a movie;
• Try a new cuisine; or
• Go out with friends who aren’t in the medical profession.

Emotional: What gives me contentment and joy? “This can be spending quality time with loved ones and friends because friends are often the first to fall through the cracks when we get busy,” says Murray. “The answer might also be a hobby that puts you ‘in the zone.’”

Spiritual: What feeds my spirit? This will be different for different people: attend church; take a walk in nature; meditate or pray; or read something inspirational.

The Eight-Step Program

Here are eight things you can do—starting now—to ensure a healthy balance in your career:

1. Select the best job for you. Keep your work-life-self balance in mind during the job search, particularly when it comes to comparing schedules, time off, benefits.
2. Consider location. If you have a family, or plan to have children soon, “choose a workplace that’s near your extended family,” advises Murray.
3. Find someone who’s doing it right. “After you start, look around and find role models who seem to be balancing their lives pretty well,” says Murray. “Look for the physician who’s not stressed, who’s juggling a family and work. Then ask them how they do it so well. Having a role model like this is really important.”
4. Talk about work. “There’s a temptation to isolate yourself and work really long hours,” warns Murray. “Grab a cup of coffee with a colleague or go for a walk with a friend.”
5. Be aware of stress. “You need to feel you’re in control of something—so control your reaction to stress,” says Murray. “Read about stress, but let go of the idea that coping with it is out of your hands.”
6. Plan ahead. Have a contingency plan for things that need to be done. “Ask yourself, ‘What’s my backup plan for childcare … and what’s my backup to the backup?’ ” says Murray. When you plan ahead, you can avoid stressful situations.
7. Laugh. “Laughter releases endorphins, which make you feel good,” Murray points out. “Seek the company of those you laugh with. And when you have options for what to watch on TV or on DVD, always choose the comedy.”
8. State your needs. “People need to communicate their needs about life balance,” Murray stresses. “This can be very difficult to do, whether it’s to your partner or your boss. State what you need in a positive way. ”

Be vigilant in maintaining a healthy work-life-self balance, with an emphasis on self, and your hospitalist career should be a happy one. TH

When you start work as a hospitalist, you’ll tend to immerse yourself in your new job. But you should also strive to maintain a work-life balance from the start, to guard against eventual burnout.

“It’s really work-family-self balance, because of the importance of self-care,” says Maureen Murray of Maureen Murray Associates in Pittsburgh, who provides professional training in stress management and work-life balance. “Self-care is more than just running or dieting—it’s the foundation of a balanced life.”

Areas of Self-Care

“If you don’t put yourself first, you won’t be very effective at caring for others,” says Murray. Her training program categorizes self-care into four areas:

Physical: What keeps me healthy? “Most people already know the answer to this,” says Murray. “Some form of regular activity, eating reasonably well, and getting some rest.” Mental: What energizes my mind? The answer is “something different,” according to Murray.

• Read a book or see a movie;
• Try a new cuisine; or
• Go out with friends who aren’t in the medical profession.

Emotional: What gives me contentment and joy? “This can be spending quality time with loved ones and friends because friends are often the first to fall through the cracks when we get busy,” says Murray. “The answer might also be a hobby that puts you ‘in the zone.’”

Spiritual: What feeds my spirit? This will be different for different people: attend church; take a walk in nature; meditate or pray; or read something inspirational.

The Eight-Step Program

Here are eight things you can do—starting now—to ensure a healthy balance in your career:

1. Select the best job for you. Keep your work-life-self balance in mind during the job search, particularly when it comes to comparing schedules, time off, benefits.
2. Consider location. If you have a family, or plan to have children soon, “choose a workplace that’s near your extended family,” advises Murray.
3. Find someone who’s doing it right. “After you start, look around and find role models who seem to be balancing their lives pretty well,” says Murray. “Look for the physician who’s not stressed, who’s juggling a family and work. Then ask them how they do it so well. Having a role model like this is really important.”
4. Talk about work. “There’s a temptation to isolate yourself and work really long hours,” warns Murray. “Grab a cup of coffee with a colleague or go for a walk with a friend.”
5. Be aware of stress. “You need to feel you’re in control of something—so control your reaction to stress,” says Murray. “Read about stress, but let go of the idea that coping with it is out of your hands.”
6. Plan ahead. Have a contingency plan for things that need to be done. “Ask yourself, ‘What’s my backup plan for childcare … and what’s my backup to the backup?’ ” says Murray. When you plan ahead, you can avoid stressful situations.
7. Laugh. “Laughter releases endorphins, which make you feel good,” Murray points out. “Seek the company of those you laugh with. And when you have options for what to watch on TV or on DVD, always choose the comedy.”
8. State your needs. “People need to communicate their needs about life balance,” Murray stresses. “This can be very difficult to do, whether it’s to your partner or your boss. State what you need in a positive way. ”

Be vigilant in maintaining a healthy work-life-self balance, with an emphasis on self, and your hospitalist career should be a happy one. TH

When you start work as a hospitalist, you’ll tend to immerse yourself in your new job. But you should also strive to maintain a work-life balance from the start, to guard against eventual burnout.

“It’s really work-family-self balance, because of the importance of self-care,” says Maureen Murray of Maureen Murray Associates in Pittsburgh, who provides professional training in stress management and work-life balance. “Self-care is more than just running or dieting—it’s the foundation of a balanced life.”

Areas of Self-Care

“If you don’t put yourself first, you won’t be very effective at caring for others,” says Murray. Her training program categorizes self-care into four areas:

Physical: What keeps me healthy? “Most people already know the answer to this,” says Murray. “Some form of regular activity, eating reasonably well, and getting some rest.” Mental: What energizes my mind? The answer is “something different,” according to Murray.

• Read a book or see a movie;
• Try a new cuisine; or
• Go out with friends who aren’t in the medical profession.

Emotional: What gives me contentment and joy? “This can be spending quality time with loved ones and friends because friends are often the first to fall through the cracks when we get busy,” says Murray. “The answer might also be a hobby that puts you ‘in the zone.’”

Spiritual: What feeds my spirit? This will be different for different people: attend church; take a walk in nature; meditate or pray; or read something inspirational.

The Eight-Step Program

Here are eight things you can do—starting now—to ensure a healthy balance in your career:

1. Select the best job for you. Keep your work-life-self balance in mind during the job search, particularly when it comes to comparing schedules, time off, benefits.
2. Consider location. If you have a family, or plan to have children soon, “choose a workplace that’s near your extended family,” advises Murray.
3. Find someone who’s doing it right. “After you start, look around and find role models who seem to be balancing their lives pretty well,” says Murray. “Look for the physician who’s not stressed, who’s juggling a family and work. Then ask them how they do it so well. Having a role model like this is really important.”
4. Talk about work. “There’s a temptation to isolate yourself and work really long hours,” warns Murray. “Grab a cup of coffee with a colleague or go for a walk with a friend.”
5. Be aware of stress. “You need to feel you’re in control of something—so control your reaction to stress,” says Murray. “Read about stress, but let go of the idea that coping with it is out of your hands.”
6. Plan ahead. Have a contingency plan for things that need to be done. “Ask yourself, ‘What’s my backup plan for childcare … and what’s my backup to the backup?’ ” says Murray. When you plan ahead, you can avoid stressful situations.
7. Laugh. “Laughter releases endorphins, which make you feel good,” Murray points out. “Seek the company of those you laugh with. And when you have options for what to watch on TV or on DVD, always choose the comedy.”
8. State your needs. “People need to communicate their needs about life balance,” Murray stresses. “This can be very difficult to do, whether it’s to your partner or your boss. State what you need in a positive way. ”

Be vigilant in maintaining a healthy work-life-self balance, with an emphasis on self, and your hospitalist career should be a happy one. TH

Recent developments at the American Board of Internal Medicine (ABIM) could affect your re-certification process as a working hospitalist. In 2004 SHM petitioned the ABIM to consider a program that would recognize the specific skills and knowledge of hospitalists. Last fall, ABIM voted to begin development of a Focused Recognition of Hospital Medicine through its Maintenance of Certification (MOC) system.

This focused recognition would give hospitalists a formal credential that recognizes hospital medicine as a distinct field within internal medicine. This is the first time in its history that ABIM has offered focused recognition for any subset of internal medicine, and—if approved—the first time that the umbrella organization, the American Board of Medical Specialties (ABMS), will offer a focused recognition for a subset of any specialty.

The Details

Robert Wachter, MD, professor of medicine at the University of California, San Francisco, is chair of ABIM’s Committee on Hospital Medicine Focused Recognition (HMFR). This committee is finalizing the details of how the focused recognition will work. Issues on their agenda include:

• Demonstration of a focused practice: The committee is considering setting a minimum volume of hospitalized patients for this that can reasonably apply to academic physicians, physician-administrators, and researchers—as well as clinical hospitalists.
• Requirements for demonstrating performance in practice: For MOC requirements, ABIM is increasingly examining the use of real practice data. In other words, measuring what physicians do rather than what they know.
• Tests for MOC: The exam for MOC with Focused Recognition of Hospital Medicine could be taken from the current MOC, with the same core content on internal medicine as well as new content relevant to hospital medicine, or it could be an entirely different test, focusing on hospital medicine.

The timeframe for an MOC with a Focused Recognition of Hospital Medicine is likely to be shorter than a standard MOC. “The minimum number of years that would elapse is still being discussed, but it would be no fewer than two and no more than four or five,” says Dr. Wachter. “Now, you don’t have to do an MOC until year 10. I’m hoping that people would start working toward their MOC as soon as they end their residency, but—people being people—they may not actually start work on this until year nine.”

What the Future Holds

In June the Committee on HMFR will present its recommendations for the process to the ABIM board, including how HMFR would relate to the rest of ABIM certification and MOC in internal medicine. Once approved, the plan will be presented to ABMS. “It will have to go through a process at ABMS, which takes a year or 18 months,” warns Holly Humphrey, MD, professor of medicine and dean for Medical Education at Pritzker School of Medicine, University of Chicago.

The goal is not to limit the practice of hospital medicine to those who have been through the focused recognition certification, but rather to lend credibility to the field. “What may change is that people hiring hospitalists may value this,” speculates Dr. Wachter. “The market will dictate” how necessary the re-certification becomes. TH

Recent developments at the American Board of Internal Medicine (ABIM) could affect your re-certification process as a working hospitalist. In 2004 SHM petitioned the ABIM to consider a program that would recognize the specific skills and knowledge of hospitalists. Last fall, ABIM voted to begin development of a Focused Recognition of Hospital Medicine through its Maintenance of Certification (MOC) system.

This focused recognition would give hospitalists a formal credential that recognizes hospital medicine as a distinct field within internal medicine. This is the first time in its history that ABIM has offered focused recognition for any subset of internal medicine, and—if approved—the first time that the umbrella organization, the American Board of Medical Specialties (ABMS), will offer a focused recognition for a subset of any specialty.

The Details

Robert Wachter, MD, professor of medicine at the University of California, San Francisco, is chair of ABIM’s Committee on Hospital Medicine Focused Recognition (HMFR). This committee is finalizing the details of how the focused recognition will work. Issues on their agenda include:

• Demonstration of a focused practice: The committee is considering setting a minimum volume of hospitalized patients for this that can reasonably apply to academic physicians, physician-administrators, and researchers—as well as clinical hospitalists.
• Requirements for demonstrating performance in practice: For MOC requirements, ABIM is increasingly examining the use of real practice data. In other words, measuring what physicians do rather than what they know.
• Tests for MOC: The exam for MOC with Focused Recognition of Hospital Medicine could be taken from the current MOC, with the same core content on internal medicine as well as new content relevant to hospital medicine, or it could be an entirely different test, focusing on hospital medicine.

The timeframe for an MOC with a Focused Recognition of Hospital Medicine is likely to be shorter than a standard MOC. “The minimum number of years that would elapse is still being discussed, but it would be no fewer than two and no more than four or five,” says Dr. Wachter. “Now, you don’t have to do an MOC until year 10. I’m hoping that people would start working toward their MOC as soon as they end their residency, but—people being people—they may not actually start work on this until year nine.”

What the Future Holds

In June the Committee on HMFR will present its recommendations for the process to the ABIM board, including how HMFR would relate to the rest of ABIM certification and MOC in internal medicine. Once approved, the plan will be presented to ABMS. “It will have to go through a process at ABMS, which takes a year or 18 months,” warns Holly Humphrey, MD, professor of medicine and dean for Medical Education at Pritzker School of Medicine, University of Chicago.

The goal is not to limit the practice of hospital medicine to those who have been through the focused recognition certification, but rather to lend credibility to the field. “What may change is that people hiring hospitalists may value this,” speculates Dr. Wachter. “The market will dictate” how necessary the re-certification becomes. TH

Recent developments at the American Board of Internal Medicine (ABIM) could affect your re-certification process as a working hospitalist. In 2004 SHM petitioned the ABIM to consider a program that would recognize the specific skills and knowledge of hospitalists. Last fall, ABIM voted to begin development of a Focused Recognition of Hospital Medicine through its Maintenance of Certification (MOC) system.

This focused recognition would give hospitalists a formal credential that recognizes hospital medicine as a distinct field within internal medicine. This is the first time in its history that ABIM has offered focused recognition for any subset of internal medicine, and—if approved—the first time that the umbrella organization, the American Board of Medical Specialties (ABMS), will offer a focused recognition for a subset of any specialty.

The Details

Robert Wachter, MD, professor of medicine at the University of California, San Francisco, is chair of ABIM’s Committee on Hospital Medicine Focused Recognition (HMFR). This committee is finalizing the details of how the focused recognition will work. Issues on their agenda include:

• Demonstration of a focused practice: The committee is considering setting a minimum volume of hospitalized patients for this that can reasonably apply to academic physicians, physician-administrators, and researchers—as well as clinical hospitalists.
• Requirements for demonstrating performance in practice: For MOC requirements, ABIM is increasingly examining the use of real practice data. In other words, measuring what physicians do rather than what they know.
• Tests for MOC: The exam for MOC with Focused Recognition of Hospital Medicine could be taken from the current MOC, with the same core content on internal medicine as well as new content relevant to hospital medicine, or it could be an entirely different test, focusing on hospital medicine.

The timeframe for an MOC with a Focused Recognition of Hospital Medicine is likely to be shorter than a standard MOC. “The minimum number of years that would elapse is still being discussed, but it would be no fewer than two and no more than four or five,” says Dr. Wachter. “Now, you don’t have to do an MOC until year 10. I’m hoping that people would start working toward their MOC as soon as they end their residency, but—people being people—they may not actually start work on this until year nine.”

What the Future Holds

In June the Committee on HMFR will present its recommendations for the process to the ABIM board, including how HMFR would relate to the rest of ABIM certification and MOC in internal medicine. Once approved, the plan will be presented to ABMS. “It will have to go through a process at ABMS, which takes a year or 18 months,” warns Holly Humphrey, MD, professor of medicine and dean for Medical Education at Pritzker School of Medicine, University of Chicago.

The goal is not to limit the practice of hospital medicine to those who have been through the focused recognition certification, but rather to lend credibility to the field. “What may change is that people hiring hospitalists may value this,” speculates Dr. Wachter. “The market will dictate” how necessary the re-certification becomes. TH

Heather A. Harris, MD, director of Eden Inpatient Services at Eden Medical Center in Castro Valley, Calif., has been a hospitalist for nearly four years and helped start her hospital medicine practice, which currently employs eight full-time day hospitalists and “a cadre of night folks.”

“I’ve been on both ends of looking for a job and hiring hospitalists,” she says. Below, she and other hospitalists share advice on how to choose your first position in hospital medicine.

Begin Early

The best job search begins before you graduate. “When you’re looking for a job, start as early as possible,” advises Sameer Badlani, MD, hospitalist and instructor at the University of Chicago. “Most people don’t realize how long it takes.”

To prepare for employment, take steps toward getting your medical license and put your paperwork in order. “If you know which state or states you want to be in, go ahead and start the state licensing as soon as possible,” says Dr. Badlani. “Each state has its own set of forms, and you can at least have the packet ready to send in.”

You can also prepare your certification materials so that they are ready to turn over to your future employer: “The FCVS [Federation Credentials Verification Service] is a repository for all your training certificates,” explains Dr. Badlani. “It costs $250 to get a copy of all your certificates, and an additional $30 every time you send it out to a [potential employer]. Some states will only accept certificates from FCVS, and I think that someday all states will require this.”

As a first step for the actual job search, Dr. Harris recommends trying to network through your university and your residency program. “Your program may keep a list of where residents have gone to work; you can at least talk to recent graduates that you know,” she says. “Call them up and see how they like what they’re doing.”

You can broaden your search by joining the industry association and exploring job postings. “I’d recommend that anyone become a member of SHM,” says Dr. Harris. “There are a variety of job postings available through their Web site. You can also simply “Google” ‘hospitalist jobs,’ and find all kinds of national services, headhunters, and companies.” To view job postings t through SHM’s online Career Center, visit www.hospitalmedicine.org and click “Career Center.”

Hospitalist Sanjiv Panwala, MD, a hospitalist at Providence Medical Center, Portland, Ore., has created www.mdgrad.com, a Web site that includes portals to hospital medicine job postings.

Narrow Your Search

When you take these first steps, you’ll discover just how many positions you have to choose from. How can you narrow your job search?

“Clearly, [you have] to distinguish the things that are important to you,” says Dr. Harris. “There’s quite a distinction between an academic and community-based position; you need to think this through before you begin your job search.”

Regardless of this first decision, there are universal factors to consider. “As in any job search, you start by thinking about the area of the country you want to be in, urban versus rural, and other factors,” explains Dr. Harris. “Then you think about the things that separate [hospital medicine] programs from one another.” You’ll find you have a lot of choices.

“There seem to be [hospital medicine] jobs everywhere,” says Dr. Panwala. “The money is in Texas or the Midwest, if that’s what’s important to you.”

Once you’ve decided on your general career path and where you’d like to live and work, consider what type of work you want to do. “One thing you should think about is whether you want to see patients in critical care arenas, or just those patients on the floors,” says Dr. Harris. “These are very different populations, and require different skill sets. You should also consider whether or not you want to work with residents. Residents work in some community settings, too.”

An Academic Job Search

If you decide you want to work in an academic setting, you don’t have to go far to start your search. “I’d think you could start by talking to the head of your department and ask if they can look around and put in a word for you,” says Dr. Harris.

Mark V. Williams, MD, FACP, director of Emory Healthcare’s Hospital Medicine Unit in Atlanta and editor of The Journal of Hospital Medicine, will become chief of the new Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago later this year. He recommends scoping out how a potential employer’s hospital medicine group is perceived and treated within the institution.

“People coming out of residency should look at the amount of support provided by the department of medicine for the hospital medicine group,” he says. “Are the hospitalists active members of the department, with key faculty in leadership positions such as residency or associate residency program director, or are they being hired just to deliver clinical care? Ask if there is funded support for hospital medicine research faculty. If not, the job may be just like working in a community setting, only community settings historically pay better.”

Signs that an institution has a strong commitment to the field include the presence of a division of hospital medicine, and possibly even a hospital medicine fellowship.

Questions to Ask

Even if you’ve got your eye on a specific hospital medicine group, go though the interview process at several institutions so that you can see what the market offers. Important factors to consider include:

Who would I work for? Who owns the hospital medicine practice? “There are differences in who’s sponsoring the group,” says Dr. Harris. “It may be independent, employed by the hospital, or a national group that contracts with the hospital. The answer will give you insights into the job. You may not get the entire picture, but you’ll get a clue.” Consider whether the practice can offer opportunities for advancement—possibly even partnership—and the type of clinical or administrative work you prefer.

What type of schedule would I work? How is the schedule arranged? Consider the number of hours you’d spend on call, and the number of nights and weekends you’d be expected to cover.

“Residents don’t have a sustainable schedule, so anything that’s not ridiculous sounds good,” warns Dr. Harris. “But a seven-on, seven-off shift is very tiring and can lead to burnout over time. So consider whether a given schedule is realistic for the long-term.” Find out how many vacation days are included—or if there are none.

What is the workload? During the interviewing process, ask about the average number of encounters per day. Definitely ask those “nitty-gritty” questions about patient load, admissions, and so on, advises Dr. Harris.

Pay special attention to the number of encounters. “Seeing 18 to 20 patients a day is a lot; those are the turn-and-burn organizations that aren’t necessarily sustainable,” says Dr. Panwala. “The money offered for this may be appealing to younger hospitalists. But remember, if you’re getting paid more, nothing is free.”

Dr. Harris adds, “Ask if that includes admissions and—if there’s critical care work—ask how many of those encounters are in critical care, because those patients will take more time.”

Michael-Anthony Williams, MD, regional CMO of Sound Inpatient Physicians in Denver, advises job seekers to look at “what they have to do” for the salary offered. “Look at … the number of days worked, the length of those days, and the number of encounters per day. You have to ask questions about these things, because the information isn’t necessarily going to be laid out in front of you.”

What about compensation and benefits? Your first consideration of salary, benefits, and other compensation should be to ensure the figures are in line with what the market offers. You can find general information on what hospitalists make from SHM’s “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org. The Medical Group Management Association (MGMA) and the Association of American Medical Colleges (AAMC) provide salary scales, and salaries for positions at public institutions like university hospitals are public information.

Do your homework, and then simply ask each interviewer what the salary range is for hospitalists. “It doesn’t put me off to have these discussions [on compensation and benefits] early on,” says Dr. Harris.

You may be tempted to choose a job based on salary—but be careful: “Don’t always look at the amount of money as the deciding factor,” says Dr. Badlani. “If a job offers $5,000 or $10,000 more, what are they expecting for that extra salary? And consider how much of that additional money will go to taxes.”

As you gather information on these areas, you’ll need to keep it straight. Dr. Harris advises you to create a simple system that allows you to compare hospital medicine practices you’re considering. “Come up with a chart and list out everything,” she says. “It’s going to vary considerably” from practice to practice, and you’ll need a method to compare one job possibility with another.

How the Process Works

Here is how the interviewing process is likely to flow: “Generally, people send me their resumes, then I’ll have a phone interview with the best candidates,” says Dr. Harris. “If that works out, the next step is that they’ll come in for a tour of the hospital and meet some of the other folks in the group.”

Candidates are invited to call or e-mail physicians in the group with questions; the group will decide which candidate to hire.

That face-to-face meeting with members of the group is essential. “Spend time with other hospitalists,” advises Dr. Badlani. “See what their daily work looks like, including what kind of patients you’ll be seeing.”

You should ask those hospitalists some of the same questions you’ve asked your main interviewer, including questions about schedule, workload, and compensation. “Talk to as many people in the practice as possible,” says Dr. Michael-Anthony Williams. “They’ll give you an honest answer.”

If you like what you see and the group likes you, you’ll get a job offer followed by a contract to sign. “When we extend an offer, they have time to determine what they want,” says Dr. Harris, explaining that she realizes a candidate may be faced with several job options. “When they say yes, we’ll extend a contract and begin the credentialing process.”

The process is not over at this point; you may be months away from your first day on the job. “You need to become credentialed for each hospital you’ll work at, and for the group,” explains Dr. Harris. “At our hospital, that can take three to four months—other places take around two months. Just so you know that you shouldn’t be looking for a job in June and thinking you’ll work in July.”

You’ll have a part to play in the credentialing process. There will be paperwork to fill out, and you’ll need to provide your diploma and medical license and letters of support. “The credentialing committee at our hospital won’t proceed until [all of this] is 100% complete,” says Dr. Harris.

Find a Good Fit

The most important factor to consider in taking a job is simply, are you a good fit for the group? Finding a good match for the group’s values and mission is crucial to the success of the organization and the new hire.

When you meet with hospitalists in the group, “Ask what the mission or values are of the group,” says Dr. Michael-Anthony Williams. “Do they know what their mission is—and is it coherent? Coherence will lend stability over time.”

Dr. Panwala stresses finding a “like-minded” group. “You’ll work with them day in and day out. If you don’t mesh well, you’re going to be miserable,” he says. “You turn your patient over to another hospitalist at 8 p.m., and when you come in the next morning, you take over someone else’s patients. It’s very much a marriage.”

What Interviewers Look For

Because its essential to find a good personality fit for a group, allow decision-makers to get a sense of who you are during the interview phase.

“It’s important to be honest about your values and about who you are,” says Dr. Harris. She believes that most hospital medicine directors look for candidates who are “actively interested in being a hospitalist—preferably for a long time,” for physicians who are team players, and for traits that include flexibility and responsibility.

“I look for someone who’s outgoing,” adds Dr. Mark Williams. “ I want a nice person—someone who’s willing to bend over backward to help others. I appreciate people who’ve won humanitarian awards in residency.”

There are also more basic traits you should display. “General etiquette is important,” stresses Dr. Harris. “Be prompt in your responses when using phone and e-mail. If you’re interested in the position, be engaged in the process. After you come in to the hospital, send a brief letter or a quick e-mail thanking the person and expressing your interest—or your lack of interest. This doesn’t have to be very formal.”

When interviewing candidates for academic hospitalist positions, Dr. Mark Williams says, “I look for residents who have won awards, who have laudatory letters of recommendation from their program director. I love letters that say this resident was in the top of their class, or the best we’ve seen in five years. I look for those who have done research, and those who published case report abstracts, which shows they’re industrious.”

Dr. Mark Williams also asks questions of candidates early in the process and listens carefully to their responses. “I especially look for good communication skills, which are so critical for hospitalists,” he says. “If someone has poor communication skills, they’ll have a tough time on the job.”

To determine their skills, “I’ll ask about their goals, and ask what they see as their weakness,” he says. “It’s very positive to see someone articulate their weaknesses.”

Before You Sign

When you’re presented with a contract, it’s time to take a close look at what’s being offered. “Before you sign anything, you need to come to an agreement with the other party in the contract that this is exactly what we agreed to. Otherwise, it’s no deal,” says Fred A. McCurdy, MD, PhD, MBA, FAAP, FACPE, professor and regional chairman of pediatrics, Texas Tech University Health Sciences Center at Amarillo. “Everything needs to be really specific in the offer letter or the contract—their duties, expectations—all clarified up front.”

Examine the benefits, including retirement and insurance. Ideally, you want disability insurance—and malpractice insurance with tail coverage is essential. (Tail coverage, also called extended reporting coverage, covers you after you leave a group in case a patient files a lawsuit years after the fact.)

Make sure you understand what the contract says, and make sure your employer doesn’t hold too much power. “Check to see if you can be assigned to areas of work that would be a deal-breaker—if you can be sent to another city or state to work, for example,” says Dr. McCurdy.

As a new physician, you do have some leverage to negotiate for better compensation or schedule. Dr. McCurdy says of recent residents, “The two biggest benefits they bring to the table are their youth and the fact that they’re current and up to date on what’s going on in [internal medicine]. They have energy, and they’ll bring energy to the program; and they’ve spent three years in intense study and have the most up-to-date knowledge of anyone you can hire.”

Point out these advantages to the right interviewer, and you may be able to negotiate.

Dr. Badlani encourages new hires to negotiate their moving expenses, bonuses, and malpractice insurance.

But keep in mind that not all hospital medicine programs can or will negotiate. “It’s quite variable,” admits Dr. McCurdy.

Dr. Harris’ program is a prime example. “In my experience, we don’t have a tremendous amount of negotiating,” she says. “Basically, we say, ‘Here’s the deal.’ ”

Dr. McCurdy advises having someone else read the contract for you. “When you’re enthusiastic about a new job, you don’t see everything,” he explains. “And you need to have a lawyer read it to make sure it’s a correctly constructed legal document.”

Dr. Harris simply advises that you “read through the contract with a fine-tooth comb. Does it have a non-compete clause that prohibits you from practicing in the region after you leave? You can find a job [locally] without this clause.”

Dr. McCurdy has allowed new hires to strike these clauses from their contracts, but it’s a trade-off. “Non-compete clauses are hard to enforce,” he acknowledges. “Our boilerplate contract has one, because we want to send the message that we don’t want to spend two years training you and then have you leave and go to work for the competition. So if [a candidate] wants to strike that clause from the contract, I’ll say that’s fine, but on the basis of that I’ll make it a binding three-year contract.”

What if, after researching, interviewing, reviewing the contract, and taking every step possible to ensure you get the best job, you find you’ve made a mistake? “Remember, your contract is only for one year,” Dr. Badlani points out. “You can always change next year if you don’t like your [first choice].” TH

Heather A. Harris, MD, director of Eden Inpatient Services at Eden Medical Center in Castro Valley, Calif., has been a hospitalist for nearly four years and helped start her hospital medicine practice, which currently employs eight full-time day hospitalists and “a cadre of night folks.”

“I’ve been on both ends of looking for a job and hiring hospitalists,” she says. Below, she and other hospitalists share advice on how to choose your first position in hospital medicine.

Begin Early

The best job search begins before you graduate. “When you’re looking for a job, start as early as possible,” advises Sameer Badlani, MD, hospitalist and instructor at the University of Chicago. “Most people don’t realize how long it takes.”

To prepare for employment, take steps toward getting your medical license and put your paperwork in order. “If you know which state or states you want to be in, go ahead and start the state licensing as soon as possible,” says Dr. Badlani. “Each state has its own set of forms, and you can at least have the packet ready to send in.”

You can also prepare your certification materials so that they are ready to turn over to your future employer: “The FCVS [Federation Credentials Verification Service] is a repository for all your training certificates,” explains Dr. Badlani. “It costs $250 to get a copy of all your certificates, and an additional $30 every time you send it out to a [potential employer]. Some states will only accept certificates from FCVS, and I think that someday all states will require this.”

As a first step for the actual job search, Dr. Harris recommends trying to network through your university and your residency program. “Your program may keep a list of where residents have gone to work; you can at least talk to recent graduates that you know,” she says. “Call them up and see how they like what they’re doing.”

You can broaden your search by joining the industry association and exploring job postings. “I’d recommend that anyone become a member of SHM,” says Dr. Harris. “There are a variety of job postings available through their Web site. You can also simply “Google” ‘hospitalist jobs,’ and find all kinds of national services, headhunters, and companies.” To view job postings t through SHM’s online Career Center, visit www.hospitalmedicine.org and click “Career Center.”

Hospitalist Sanjiv Panwala, MD, a hospitalist at Providence Medical Center, Portland, Ore., has created www.mdgrad.com, a Web site that includes portals to hospital medicine job postings.

Narrow Your Search

When you take these first steps, you’ll discover just how many positions you have to choose from. How can you narrow your job search?

“Clearly, [you have] to distinguish the things that are important to you,” says Dr. Harris. “There’s quite a distinction between an academic and community-based position; you need to think this through before you begin your job search.”

Regardless of this first decision, there are universal factors to consider. “As in any job search, you start by thinking about the area of the country you want to be in, urban versus rural, and other factors,” explains Dr. Harris. “Then you think about the things that separate [hospital medicine] programs from one another.” You’ll find you have a lot of choices.

“There seem to be [hospital medicine] jobs everywhere,” says Dr. Panwala. “The money is in Texas or the Midwest, if that’s what’s important to you.”

Once you’ve decided on your general career path and where you’d like to live and work, consider what type of work you want to do. “One thing you should think about is whether you want to see patients in critical care arenas, or just those patients on the floors,” says Dr. Harris. “These are very different populations, and require different skill sets. You should also consider whether or not you want to work with residents. Residents work in some community settings, too.”

An Academic Job Search

If you decide you want to work in an academic setting, you don’t have to go far to start your search. “I’d think you could start by talking to the head of your department and ask if they can look around and put in a word for you,” says Dr. Harris.

Mark V. Williams, MD, FACP, director of Emory Healthcare’s Hospital Medicine Unit in Atlanta and editor of The Journal of Hospital Medicine, will become chief of the new Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago later this year. He recommends scoping out how a potential employer’s hospital medicine group is perceived and treated within the institution.

“People coming out of residency should look at the amount of support provided by the department of medicine for the hospital medicine group,” he says. “Are the hospitalists active members of the department, with key faculty in leadership positions such as residency or associate residency program director, or are they being hired just to deliver clinical care? Ask if there is funded support for hospital medicine research faculty. If not, the job may be just like working in a community setting, only community settings historically pay better.”

Signs that an institution has a strong commitment to the field include the presence of a division of hospital medicine, and possibly even a hospital medicine fellowship.

Questions to Ask

Even if you’ve got your eye on a specific hospital medicine group, go though the interview process at several institutions so that you can see what the market offers. Important factors to consider include:

Who would I work for? Who owns the hospital medicine practice? “There are differences in who’s sponsoring the group,” says Dr. Harris. “It may be independent, employed by the hospital, or a national group that contracts with the hospital. The answer will give you insights into the job. You may not get the entire picture, but you’ll get a clue.” Consider whether the practice can offer opportunities for advancement—possibly even partnership—and the type of clinical or administrative work you prefer.

What type of schedule would I work? How is the schedule arranged? Consider the number of hours you’d spend on call, and the number of nights and weekends you’d be expected to cover.

“Residents don’t have a sustainable schedule, so anything that’s not ridiculous sounds good,” warns Dr. Harris. “But a seven-on, seven-off shift is very tiring and can lead to burnout over time. So consider whether a given schedule is realistic for the long-term.” Find out how many vacation days are included—or if there are none.

What is the workload? During the interviewing process, ask about the average number of encounters per day. Definitely ask those “nitty-gritty” questions about patient load, admissions, and so on, advises Dr. Harris.

Pay special attention to the number of encounters. “Seeing 18 to 20 patients a day is a lot; those are the turn-and-burn organizations that aren’t necessarily sustainable,” says Dr. Panwala. “The money offered for this may be appealing to younger hospitalists. But remember, if you’re getting paid more, nothing is free.”

Dr. Harris adds, “Ask if that includes admissions and—if there’s critical care work—ask how many of those encounters are in critical care, because those patients will take more time.”

Michael-Anthony Williams, MD, regional CMO of Sound Inpatient Physicians in Denver, advises job seekers to look at “what they have to do” for the salary offered. “Look at … the number of days worked, the length of those days, and the number of encounters per day. You have to ask questions about these things, because the information isn’t necessarily going to be laid out in front of you.”

What about compensation and benefits? Your first consideration of salary, benefits, and other compensation should be to ensure the figures are in line with what the market offers. You can find general information on what hospitalists make from SHM’s “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org. The Medical Group Management Association (MGMA) and the Association of American Medical Colleges (AAMC) provide salary scales, and salaries for positions at public institutions like university hospitals are public information.

Do your homework, and then simply ask each interviewer what the salary range is for hospitalists. “It doesn’t put me off to have these discussions [on compensation and benefits] early on,” says Dr. Harris.

You may be tempted to choose a job based on salary—but be careful: “Don’t always look at the amount of money as the deciding factor,” says Dr. Badlani. “If a job offers $5,000 or $10,000 more, what are they expecting for that extra salary? And consider how much of that additional money will go to taxes.”

As you gather information on these areas, you’ll need to keep it straight. Dr. Harris advises you to create a simple system that allows you to compare hospital medicine practices you’re considering. “Come up with a chart and list out everything,” she says. “It’s going to vary considerably” from practice to practice, and you’ll need a method to compare one job possibility with another.

How the Process Works

Here is how the interviewing process is likely to flow: “Generally, people send me their resumes, then I’ll have a phone interview with the best candidates,” says Dr. Harris. “If that works out, the next step is that they’ll come in for a tour of the hospital and meet some of the other folks in the group.”

Candidates are invited to call or e-mail physicians in the group with questions; the group will decide which candidate to hire.

That face-to-face meeting with members of the group is essential. “Spend time with other hospitalists,” advises Dr. Badlani. “See what their daily work looks like, including what kind of patients you’ll be seeing.”

You should ask those hospitalists some of the same questions you’ve asked your main interviewer, including questions about schedule, workload, and compensation. “Talk to as many people in the practice as possible,” says Dr. Michael-Anthony Williams. “They’ll give you an honest answer.”

If you like what you see and the group likes you, you’ll get a job offer followed by a contract to sign. “When we extend an offer, they have time to determine what they want,” says Dr. Harris, explaining that she realizes a candidate may be faced with several job options. “When they say yes, we’ll extend a contract and begin the credentialing process.”

The process is not over at this point; you may be months away from your first day on the job. “You need to become credentialed for each hospital you’ll work at, and for the group,” explains Dr. Harris. “At our hospital, that can take three to four months—other places take around two months. Just so you know that you shouldn’t be looking for a job in June and thinking you’ll work in July.”

You’ll have a part to play in the credentialing process. There will be paperwork to fill out, and you’ll need to provide your diploma and medical license and letters of support. “The credentialing committee at our hospital won’t proceed until [all of this] is 100% complete,” says Dr. Harris.

Find a Good Fit

The most important factor to consider in taking a job is simply, are you a good fit for the group? Finding a good match for the group’s values and mission is crucial to the success of the organization and the new hire.

When you meet with hospitalists in the group, “Ask what the mission or values are of the group,” says Dr. Michael-Anthony Williams. “Do they know what their mission is—and is it coherent? Coherence will lend stability over time.”

Dr. Panwala stresses finding a “like-minded” group. “You’ll work with them day in and day out. If you don’t mesh well, you’re going to be miserable,” he says. “You turn your patient over to another hospitalist at 8 p.m., and when you come in the next morning, you take over someone else’s patients. It’s very much a marriage.”

What Interviewers Look For

Because its essential to find a good personality fit for a group, allow decision-makers to get a sense of who you are during the interview phase.

“It’s important to be honest about your values and about who you are,” says Dr. Harris. She believes that most hospital medicine directors look for candidates who are “actively interested in being a hospitalist—preferably for a long time,” for physicians who are team players, and for traits that include flexibility and responsibility.

“I look for someone who’s outgoing,” adds Dr. Mark Williams. “ I want a nice person—someone who’s willing to bend over backward to help others. I appreciate people who’ve won humanitarian awards in residency.”

There are also more basic traits you should display. “General etiquette is important,” stresses Dr. Harris. “Be prompt in your responses when using phone and e-mail. If you’re interested in the position, be engaged in the process. After you come in to the hospital, send a brief letter or a quick e-mail thanking the person and expressing your interest—or your lack of interest. This doesn’t have to be very formal.”

When interviewing candidates for academic hospitalist positions, Dr. Mark Williams says, “I look for residents who have won awards, who have laudatory letters of recommendation from their program director. I love letters that say this resident was in the top of their class, or the best we’ve seen in five years. I look for those who have done research, and those who published case report abstracts, which shows they’re industrious.”

Dr. Mark Williams also asks questions of candidates early in the process and listens carefully to their responses. “I especially look for good communication skills, which are so critical for hospitalists,” he says. “If someone has poor communication skills, they’ll have a tough time on the job.”

To determine their skills, “I’ll ask about their goals, and ask what they see as their weakness,” he says. “It’s very positive to see someone articulate their weaknesses.”

Before You Sign

When you’re presented with a contract, it’s time to take a close look at what’s being offered. “Before you sign anything, you need to come to an agreement with the other party in the contract that this is exactly what we agreed to. Otherwise, it’s no deal,” says Fred A. McCurdy, MD, PhD, MBA, FAAP, FACPE, professor and regional chairman of pediatrics, Texas Tech University Health Sciences Center at Amarillo. “Everything needs to be really specific in the offer letter or the contract—their duties, expectations—all clarified up front.”

Examine the benefits, including retirement and insurance. Ideally, you want disability insurance—and malpractice insurance with tail coverage is essential. (Tail coverage, also called extended reporting coverage, covers you after you leave a group in case a patient files a lawsuit years after the fact.)

Make sure you understand what the contract says, and make sure your employer doesn’t hold too much power. “Check to see if you can be assigned to areas of work that would be a deal-breaker—if you can be sent to another city or state to work, for example,” says Dr. McCurdy.

As a new physician, you do have some leverage to negotiate for better compensation or schedule. Dr. McCurdy says of recent residents, “The two biggest benefits they bring to the table are their youth and the fact that they’re current and up to date on what’s going on in [internal medicine]. They have energy, and they’ll bring energy to the program; and they’ve spent three years in intense study and have the most up-to-date knowledge of anyone you can hire.”

Point out these advantages to the right interviewer, and you may be able to negotiate.

Dr. Badlani encourages new hires to negotiate their moving expenses, bonuses, and malpractice insurance.

But keep in mind that not all hospital medicine programs can or will negotiate. “It’s quite variable,” admits Dr. McCurdy.

Dr. Harris’ program is a prime example. “In my experience, we don’t have a tremendous amount of negotiating,” she says. “Basically, we say, ‘Here’s the deal.’ ”

Dr. McCurdy advises having someone else read the contract for you. “When you’re enthusiastic about a new job, you don’t see everything,” he explains. “And you need to have a lawyer read it to make sure it’s a correctly constructed legal document.”

Dr. Harris simply advises that you “read through the contract with a fine-tooth comb. Does it have a non-compete clause that prohibits you from practicing in the region after you leave? You can find a job [locally] without this clause.”

Dr. McCurdy has allowed new hires to strike these clauses from their contracts, but it’s a trade-off. “Non-compete clauses are hard to enforce,” he acknowledges. “Our boilerplate contract has one, because we want to send the message that we don’t want to spend two years training you and then have you leave and go to work for the competition. So if [a candidate] wants to strike that clause from the contract, I’ll say that’s fine, but on the basis of that I’ll make it a binding three-year contract.”

What if, after researching, interviewing, reviewing the contract, and taking every step possible to ensure you get the best job, you find you’ve made a mistake? “Remember, your contract is only for one year,” Dr. Badlani points out. “You can always change next year if you don’t like your [first choice].” TH

Heather A. Harris, MD, director of Eden Inpatient Services at Eden Medical Center in Castro Valley, Calif., has been a hospitalist for nearly four years and helped start her hospital medicine practice, which currently employs eight full-time day hospitalists and “a cadre of night folks.”

“I’ve been on both ends of looking for a job and hiring hospitalists,” she says. Below, she and other hospitalists share advice on how to choose your first position in hospital medicine.

Begin Early

The best job search begins before you graduate. “When you’re looking for a job, start as early as possible,” advises Sameer Badlani, MD, hospitalist and instructor at the University of Chicago. “Most people don’t realize how long it takes.”

To prepare for employment, take steps toward getting your medical license and put your paperwork in order. “If you know which state or states you want to be in, go ahead and start the state licensing as soon as possible,” says Dr. Badlani. “Each state has its own set of forms, and you can at least have the packet ready to send in.”

You can also prepare your certification materials so that they are ready to turn over to your future employer: “The FCVS [Federation Credentials Verification Service] is a repository for all your training certificates,” explains Dr. Badlani. “It costs $250 to get a copy of all your certificates, and an additional $30 every time you send it out to a [potential employer]. Some states will only accept certificates from FCVS, and I think that someday all states will require this.”

As a first step for the actual job search, Dr. Harris recommends trying to network through your university and your residency program. “Your program may keep a list of where residents have gone to work; you can at least talk to recent graduates that you know,” she says. “Call them up and see how they like what they’re doing.”

You can broaden your search by joining the industry association and exploring job postings. “I’d recommend that anyone become a member of SHM,” says Dr. Harris. “There are a variety of job postings available through their Web site. You can also simply “Google” ‘hospitalist jobs,’ and find all kinds of national services, headhunters, and companies.” To view job postings t through SHM’s online Career Center, visit www.hospitalmedicine.org and click “Career Center.”

Hospitalist Sanjiv Panwala, MD, a hospitalist at Providence Medical Center, Portland, Ore., has created www.mdgrad.com, a Web site that includes portals to hospital medicine job postings.

Narrow Your Search

When you take these first steps, you’ll discover just how many positions you have to choose from. How can you narrow your job search?

“Clearly, [you have] to distinguish the things that are important to you,” says Dr. Harris. “There’s quite a distinction between an academic and community-based position; you need to think this through before you begin your job search.”

Regardless of this first decision, there are universal factors to consider. “As in any job search, you start by thinking about the area of the country you want to be in, urban versus rural, and other factors,” explains Dr. Harris. “Then you think about the things that separate [hospital medicine] programs from one another.” You’ll find you have a lot of choices.

“There seem to be [hospital medicine] jobs everywhere,” says Dr. Panwala. “The money is in Texas or the Midwest, if that’s what’s important to you.”

Once you’ve decided on your general career path and where you’d like to live and work, consider what type of work you want to do. “One thing you should think about is whether you want to see patients in critical care arenas, or just those patients on the floors,” says Dr. Harris. “These are very different populations, and require different skill sets. You should also consider whether or not you want to work with residents. Residents work in some community settings, too.”

An Academic Job Search

If you decide you want to work in an academic setting, you don’t have to go far to start your search. “I’d think you could start by talking to the head of your department and ask if they can look around and put in a word for you,” says Dr. Harris.

Mark V. Williams, MD, FACP, director of Emory Healthcare’s Hospital Medicine Unit in Atlanta and editor of The Journal of Hospital Medicine, will become chief of the new Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago later this year. He recommends scoping out how a potential employer’s hospital medicine group is perceived and treated within the institution.

“People coming out of residency should look at the amount of support provided by the department of medicine for the hospital medicine group,” he says. “Are the hospitalists active members of the department, with key faculty in leadership positions such as residency or associate residency program director, or are they being hired just to deliver clinical care? Ask if there is funded support for hospital medicine research faculty. If not, the job may be just like working in a community setting, only community settings historically pay better.”

Signs that an institution has a strong commitment to the field include the presence of a division of hospital medicine, and possibly even a hospital medicine fellowship.

Questions to Ask

Even if you’ve got your eye on a specific hospital medicine group, go though the interview process at several institutions so that you can see what the market offers. Important factors to consider include:

Who would I work for? Who owns the hospital medicine practice? “There are differences in who’s sponsoring the group,” says Dr. Harris. “It may be independent, employed by the hospital, or a national group that contracts with the hospital. The answer will give you insights into the job. You may not get the entire picture, but you’ll get a clue.” Consider whether the practice can offer opportunities for advancement—possibly even partnership—and the type of clinical or administrative work you prefer.

What type of schedule would I work? How is the schedule arranged? Consider the number of hours you’d spend on call, and the number of nights and weekends you’d be expected to cover.

“Residents don’t have a sustainable schedule, so anything that’s not ridiculous sounds good,” warns Dr. Harris. “But a seven-on, seven-off shift is very tiring and can lead to burnout over time. So consider whether a given schedule is realistic for the long-term.” Find out how many vacation days are included—or if there are none.

What is the workload? During the interviewing process, ask about the average number of encounters per day. Definitely ask those “nitty-gritty” questions about patient load, admissions, and so on, advises Dr. Harris.

Pay special attention to the number of encounters. “Seeing 18 to 20 patients a day is a lot; those are the turn-and-burn organizations that aren’t necessarily sustainable,” says Dr. Panwala. “The money offered for this may be appealing to younger hospitalists. But remember, if you’re getting paid more, nothing is free.”

Dr. Harris adds, “Ask if that includes admissions and—if there’s critical care work—ask how many of those encounters are in critical care, because those patients will take more time.”

Michael-Anthony Williams, MD, regional CMO of Sound Inpatient Physicians in Denver, advises job seekers to look at “what they have to do” for the salary offered. “Look at … the number of days worked, the length of those days, and the number of encounters per day. You have to ask questions about these things, because the information isn’t necessarily going to be laid out in front of you.”

What about compensation and benefits? Your first consideration of salary, benefits, and other compensation should be to ensure the figures are in line with what the market offers. You can find general information on what hospitalists make from SHM’s “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org. The Medical Group Management Association (MGMA) and the Association of American Medical Colleges (AAMC) provide salary scales, and salaries for positions at public institutions like university hospitals are public information.

Do your homework, and then simply ask each interviewer what the salary range is for hospitalists. “It doesn’t put me off to have these discussions [on compensation and benefits] early on,” says Dr. Harris.

You may be tempted to choose a job based on salary—but be careful: “Don’t always look at the amount of money as the deciding factor,” says Dr. Badlani. “If a job offers $5,000 or $10,000 more, what are they expecting for that extra salary? And consider how much of that additional money will go to taxes.”

As you gather information on these areas, you’ll need to keep it straight. Dr. Harris advises you to create a simple system that allows you to compare hospital medicine practices you’re considering. “Come up with a chart and list out everything,” she says. “It’s going to vary considerably” from practice to practice, and you’ll need a method to compare one job possibility with another.

How the Process Works

Here is how the interviewing process is likely to flow: “Generally, people send me their resumes, then I’ll have a phone interview with the best candidates,” says Dr. Harris. “If that works out, the next step is that they’ll come in for a tour of the hospital and meet some of the other folks in the group.”

Candidates are invited to call or e-mail physicians in the group with questions; the group will decide which candidate to hire.

That face-to-face meeting with members of the group is essential. “Spend time with other hospitalists,” advises Dr. Badlani. “See what their daily work looks like, including what kind of patients you’ll be seeing.”

You should ask those hospitalists some of the same questions you’ve asked your main interviewer, including questions about schedule, workload, and compensation. “Talk to as many people in the practice as possible,” says Dr. Michael-Anthony Williams. “They’ll give you an honest answer.”

If you like what you see and the group likes you, you’ll get a job offer followed by a contract to sign. “When we extend an offer, they have time to determine what they want,” says Dr. Harris, explaining that she realizes a candidate may be faced with several job options. “When they say yes, we’ll extend a contract and begin the credentialing process.”

The process is not over at this point; you may be months away from your first day on the job. “You need to become credentialed for each hospital you’ll work at, and for the group,” explains Dr. Harris. “At our hospital, that can take three to four months—other places take around two months. Just so you know that you shouldn’t be looking for a job in June and thinking you’ll work in July.”

You’ll have a part to play in the credentialing process. There will be paperwork to fill out, and you’ll need to provide your diploma and medical license and letters of support. “The credentialing committee at our hospital won’t proceed until [all of this] is 100% complete,” says Dr. Harris.

Find a Good Fit

The most important factor to consider in taking a job is simply, are you a good fit for the group? Finding a good match for the group’s values and mission is crucial to the success of the organization and the new hire.

When you meet with hospitalists in the group, “Ask what the mission or values are of the group,” says Dr. Michael-Anthony Williams. “Do they know what their mission is—and is it coherent? Coherence will lend stability over time.”

Dr. Panwala stresses finding a “like-minded” group. “You’ll work with them day in and day out. If you don’t mesh well, you’re going to be miserable,” he says. “You turn your patient over to another hospitalist at 8 p.m., and when you come in the next morning, you take over someone else’s patients. It’s very much a marriage.”

What Interviewers Look For

Because its essential to find a good personality fit for a group, allow decision-makers to get a sense of who you are during the interview phase.

“It’s important to be honest about your values and about who you are,” says Dr. Harris. She believes that most hospital medicine directors look for candidates who are “actively interested in being a hospitalist—preferably for a long time,” for physicians who are team players, and for traits that include flexibility and responsibility.

“I look for someone who’s outgoing,” adds Dr. Mark Williams. “ I want a nice person—someone who’s willing to bend over backward to help others. I appreciate people who’ve won humanitarian awards in residency.”

There are also more basic traits you should display. “General etiquette is important,” stresses Dr. Harris. “Be prompt in your responses when using phone and e-mail. If you’re interested in the position, be engaged in the process. After you come in to the hospital, send a brief letter or a quick e-mail thanking the person and expressing your interest—or your lack of interest. This doesn’t have to be very formal.”

When interviewing candidates for academic hospitalist positions, Dr. Mark Williams says, “I look for residents who have won awards, who have laudatory letters of recommendation from their program director. I love letters that say this resident was in the top of their class, or the best we’ve seen in five years. I look for those who have done research, and those who published case report abstracts, which shows they’re industrious.”

Dr. Mark Williams also asks questions of candidates early in the process and listens carefully to their responses. “I especially look for good communication skills, which are so critical for hospitalists,” he says. “If someone has poor communication skills, they’ll have a tough time on the job.”

To determine their skills, “I’ll ask about their goals, and ask what they see as their weakness,” he says. “It’s very positive to see someone articulate their weaknesses.”

Before You Sign

When you’re presented with a contract, it’s time to take a close look at what’s being offered. “Before you sign anything, you need to come to an agreement with the other party in the contract that this is exactly what we agreed to. Otherwise, it’s no deal,” says Fred A. McCurdy, MD, PhD, MBA, FAAP, FACPE, professor and regional chairman of pediatrics, Texas Tech University Health Sciences Center at Amarillo. “Everything needs to be really specific in the offer letter or the contract—their duties, expectations—all clarified up front.”

Examine the benefits, including retirement and insurance. Ideally, you want disability insurance—and malpractice insurance with tail coverage is essential. (Tail coverage, also called extended reporting coverage, covers you after you leave a group in case a patient files a lawsuit years after the fact.)

Make sure you understand what the contract says, and make sure your employer doesn’t hold too much power. “Check to see if you can be assigned to areas of work that would be a deal-breaker—if you can be sent to another city or state to work, for example,” says Dr. McCurdy.

As a new physician, you do have some leverage to negotiate for better compensation or schedule. Dr. McCurdy says of recent residents, “The two biggest benefits they bring to the table are their youth and the fact that they’re current and up to date on what’s going on in [internal medicine]. They have energy, and they’ll bring energy to the program; and they’ve spent three years in intense study and have the most up-to-date knowledge of anyone you can hire.”

Point out these advantages to the right interviewer, and you may be able to negotiate.

Dr. Badlani encourages new hires to negotiate their moving expenses, bonuses, and malpractice insurance.

But keep in mind that not all hospital medicine programs can or will negotiate. “It’s quite variable,” admits Dr. McCurdy.

Dr. Harris’ program is a prime example. “In my experience, we don’t have a tremendous amount of negotiating,” she says. “Basically, we say, ‘Here’s the deal.’ ”

Dr. McCurdy advises having someone else read the contract for you. “When you’re enthusiastic about a new job, you don’t see everything,” he explains. “And you need to have a lawyer read it to make sure it’s a correctly constructed legal document.”

Dr. Harris simply advises that you “read through the contract with a fine-tooth comb. Does it have a non-compete clause that prohibits you from practicing in the region after you leave? You can find a job [locally] without this clause.”

Dr. McCurdy has allowed new hires to strike these clauses from their contracts, but it’s a trade-off. “Non-compete clauses are hard to enforce,” he acknowledges. “Our boilerplate contract has one, because we want to send the message that we don’t want to spend two years training you and then have you leave and go to work for the competition. So if [a candidate] wants to strike that clause from the contract, I’ll say that’s fine, but on the basis of that I’ll make it a binding three-year contract.”

What if, after researching, interviewing, reviewing the contract, and taking every step possible to ensure you get the best job, you find you’ve made a mistake? “Remember, your contract is only for one year,” Dr. Badlani points out. “You can always change next year if you don’t like your [first choice].” TH

A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”

Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.

Six Ways to Shape Your Residency Toward Hospital Medicine

1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”

A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.

2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.

“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”

Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”

Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”

Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”

The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”

3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.

She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”

Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.

4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).

“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”

Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”

Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”

5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.

“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”

Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”

6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)

“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.

Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.

Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH

A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”

Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.

Six Ways to Shape Your Residency Toward Hospital Medicine

1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”

A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.

2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.

“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”

Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”

Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”

Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”

The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”

3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.

She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”

Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.

4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).

“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”

Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”

Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”

5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.

“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”

Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”

6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)

“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.

Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.

Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH

A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”

Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.

Six Ways to Shape Your Residency Toward Hospital Medicine

1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”

A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.

2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.

“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”

Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”

Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”

Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”

The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”

3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.

She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”

Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.

4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).

“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”

Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”

Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”

5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.

“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”

Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”

6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)

“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.

Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.

Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH