How prepared are you to negotiate the best possible contract for your next position? Do you know what you can realistically ask for? If the salary offered seems too low, do other factors make the job a perfect fit?

In order to get the most beneficial contract with your next hospitalist position, you must have confidence in your negotiation skills. Here are some steps that may help.

1. Recognize Your Priorities

Before you set foot in your first interview with an organization, you must know your own mind—what exactly do you want to “win” in a contract negotiation?

“Your first step should be quiet reflection, where you figure out what you want and what [part] of that is non-negotiable,” advises Fred A. McCurdy, MD, PhD, MBA, FAAP, CPE, professor and regional chairman of the department of pediatrics, Texas Tech University Health Sciences Center at Amarillo. Most people focus on money when they anticipate negotiating employment, but there are other factors to consider, such as schedule (on-duty and on-call hours); opportunities for advancement, including research, project management, and teaching; and, of course, benefits, including insurance and retirement packages. Consider carefully which factors matter most to you, then rank them to organize your personal priorities.

Dr. McCurdy recommends the process he uses for all the negotiations he participates in as part of his job. “I think through the principles of each negotiation situation and write them out,” he says. “I pick out the non-negotiable items as well as the items I hope to achieve.”

2. Do Your Homework

It’s tough to negotiate your salary or your benefits when you don’t know the market. “Don’t walk in without knowing your facts,” warns Dr. McCurdy. “Do your homework to see what the market is and how payment systems work.”

Research the potential employer to find out what they’re paying other physicians and how they pay. “You can ask [the interviewers], ‘What are you currently paying your other hospitalists?’ ” says Dr. McCurdy. “You might get [them to tell you] a pay range.”

Ask questions in your interviews, and conduct independent research on the organization and on the market.

“You can obtain a lot of information on your own,” he explains. “The MGMA [Medical Group Management Association] and the Association of American Medical Colleges (AAMC) have salary scales available. Salaries are public information for people who work in public institutions like university hospitals.”

SHM also provides up-to-date salary information in its “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org.

3. Know Your Strengths

Another homework assignment before the interview process: Know your strongest selling points. Whether you have an excellent record as a faculty member or a strong background in heading up task forces, your unique strengths will be your strongest argument in negotiating your contract.

“The most effective way to negotiate is to talk about the value-added,” says Dr. McCurdy. “Find out what they want, and speak to that. You’ll have to figure that out as you go.”

It might be what you can do to improve the organization’s bottom line; it might be specific skills or expertise you bring to the table, such as teaching proficiency or research skills.

What about recent graduates who are seeking their first job as a hospitalist? “People right out of training seem to have distinct advantages that they don’t emphasize,” says Dr. McCurdy. “They’re young and have a high energy level, for one thing. Their knowledge base is very current, so they’re cutting edge, and they have quality of training—they were recently instructed by cutting-edge teachers.”

4. Look Beyond Salary

Of course you’ll want to negotiate for as much money as you can, but other factors may make a lower salary worthwhile to you. “Lots of organizations have a lot of non-tangibles to offer, but many physicians go into this ill informed” about what they can get, says Dr. McCurdy. You might ask for “some equity holding in the organization you’re looking to become part of” if it’s a privately held hospital medicine group.

“Think about various trade-offs,” urges Dr. McCurdy. “For example, you might accept a lower salary for less on-call time. Or if you’re considering a position in academic medicine, you know that your residents will take most of your night hours—is that worth a lower salary to you?”

You might also consider “access to a foundation that could help you leverage a project you want to do or a situation where you have a chance to spin off intellectual property where you keep the proceeds,” he suggests. “It all depends on the organization. What do they have that would be valuable to you?”

5. Practice Your Negotiation Skills

One last piece of homework before you walk into the final interview: Do a practice run of how the meeting might go.

Physicians don’t always practice negotiation conversations, says Dr. McCurdy. “Find someone who will practice with you, who will throw a lot of questions at you. I used a personal coach. She had me practicing ‘how to deal with Fred when he’s in conflict.’ I hated it, and I’m so glad I did it!”

So do your homework and be prepared to argue your strengths, stick up for your non-negotiables, and resign yourself to giving in on some of your other points. With insight, information, and practice, you’ll be in an excellent position to walk away from the table with most—if not all—of what you want in your next contract. TH

Jane Jerrard writes “Career Management” monthly for The Hospitalist.

How prepared are you to negotiate the best possible contract for your next position? Do you know what you can realistically ask for? If the salary offered seems too low, do other factors make the job a perfect fit?

In order to get the most beneficial contract with your next hospitalist position, you must have confidence in your negotiation skills. Here are some steps that may help.

1. Recognize Your Priorities

Before you set foot in your first interview with an organization, you must know your own mind—what exactly do you want to “win” in a contract negotiation?

“Your first step should be quiet reflection, where you figure out what you want and what [part] of that is non-negotiable,” advises Fred A. McCurdy, MD, PhD, MBA, FAAP, CPE, professor and regional chairman of the department of pediatrics, Texas Tech University Health Sciences Center at Amarillo. Most people focus on money when they anticipate negotiating employment, but there are other factors to consider, such as schedule (on-duty and on-call hours); opportunities for advancement, including research, project management, and teaching; and, of course, benefits, including insurance and retirement packages. Consider carefully which factors matter most to you, then rank them to organize your personal priorities.

Dr. McCurdy recommends the process he uses for all the negotiations he participates in as part of his job. “I think through the principles of each negotiation situation and write them out,” he says. “I pick out the non-negotiable items as well as the items I hope to achieve.”

2. Do Your Homework

It’s tough to negotiate your salary or your benefits when you don’t know the market. “Don’t walk in without knowing your facts,” warns Dr. McCurdy. “Do your homework to see what the market is and how payment systems work.”

Research the potential employer to find out what they’re paying other physicians and how they pay. “You can ask [the interviewers], ‘What are you currently paying your other hospitalists?’ ” says Dr. McCurdy. “You might get [them to tell you] a pay range.”

Ask questions in your interviews, and conduct independent research on the organization and on the market.

“You can obtain a lot of information on your own,” he explains. “The MGMA [Medical Group Management Association] and the Association of American Medical Colleges (AAMC) have salary scales available. Salaries are public information for people who work in public institutions like university hospitals.”

SHM also provides up-to-date salary information in its “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org.

3. Know Your Strengths

Another homework assignment before the interview process: Know your strongest selling points. Whether you have an excellent record as a faculty member or a strong background in heading up task forces, your unique strengths will be your strongest argument in negotiating your contract.

“The most effective way to negotiate is to talk about the value-added,” says Dr. McCurdy. “Find out what they want, and speak to that. You’ll have to figure that out as you go.”

It might be what you can do to improve the organization’s bottom line; it might be specific skills or expertise you bring to the table, such as teaching proficiency or research skills.

What about recent graduates who are seeking their first job as a hospitalist? “People right out of training seem to have distinct advantages that they don’t emphasize,” says Dr. McCurdy. “They’re young and have a high energy level, for one thing. Their knowledge base is very current, so they’re cutting edge, and they have quality of training—they were recently instructed by cutting-edge teachers.”

4. Look Beyond Salary

Of course you’ll want to negotiate for as much money as you can, but other factors may make a lower salary worthwhile to you. “Lots of organizations have a lot of non-tangibles to offer, but many physicians go into this ill informed” about what they can get, says Dr. McCurdy. You might ask for “some equity holding in the organization you’re looking to become part of” if it’s a privately held hospital medicine group.

“Think about various trade-offs,” urges Dr. McCurdy. “For example, you might accept a lower salary for less on-call time. Or if you’re considering a position in academic medicine, you know that your residents will take most of your night hours—is that worth a lower salary to you?”

You might also consider “access to a foundation that could help you leverage a project you want to do or a situation where you have a chance to spin off intellectual property where you keep the proceeds,” he suggests. “It all depends on the organization. What do they have that would be valuable to you?”

5. Practice Your Negotiation Skills

One last piece of homework before you walk into the final interview: Do a practice run of how the meeting might go.

Physicians don’t always practice negotiation conversations, says Dr. McCurdy. “Find someone who will practice with you, who will throw a lot of questions at you. I used a personal coach. She had me practicing ‘how to deal with Fred when he’s in conflict.’ I hated it, and I’m so glad I did it!”

So do your homework and be prepared to argue your strengths, stick up for your non-negotiables, and resign yourself to giving in on some of your other points. With insight, information, and practice, you’ll be in an excellent position to walk away from the table with most—if not all—of what you want in your next contract. TH

Jane Jerrard writes “Career Management” monthly for The Hospitalist.

How prepared are you to negotiate the best possible contract for your next position? Do you know what you can realistically ask for? If the salary offered seems too low, do other factors make the job a perfect fit?

In order to get the most beneficial contract with your next hospitalist position, you must have confidence in your negotiation skills. Here are some steps that may help.

1. Recognize Your Priorities

Before you set foot in your first interview with an organization, you must know your own mind—what exactly do you want to “win” in a contract negotiation?

“Your first step should be quiet reflection, where you figure out what you want and what [part] of that is non-negotiable,” advises Fred A. McCurdy, MD, PhD, MBA, FAAP, CPE, professor and regional chairman of the department of pediatrics, Texas Tech University Health Sciences Center at Amarillo. Most people focus on money when they anticipate negotiating employment, but there are other factors to consider, such as schedule (on-duty and on-call hours); opportunities for advancement, including research, project management, and teaching; and, of course, benefits, including insurance and retirement packages. Consider carefully which factors matter most to you, then rank them to organize your personal priorities.

Dr. McCurdy recommends the process he uses for all the negotiations he participates in as part of his job. “I think through the principles of each negotiation situation and write them out,” he says. “I pick out the non-negotiable items as well as the items I hope to achieve.”

2. Do Your Homework

It’s tough to negotiate your salary or your benefits when you don’t know the market. “Don’t walk in without knowing your facts,” warns Dr. McCurdy. “Do your homework to see what the market is and how payment systems work.”

Research the potential employer to find out what they’re paying other physicians and how they pay. “You can ask [the interviewers], ‘What are you currently paying your other hospitalists?’ ” says Dr. McCurdy. “You might get [them to tell you] a pay range.”

Ask questions in your interviews, and conduct independent research on the organization and on the market.

“You can obtain a lot of information on your own,” he explains. “The MGMA [Medical Group Management Association] and the Association of American Medical Colleges (AAMC) have salary scales available. Salaries are public information for people who work in public institutions like university hospitals.”

SHM also provides up-to-date salary information in its “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org.

3. Know Your Strengths

Another homework assignment before the interview process: Know your strongest selling points. Whether you have an excellent record as a faculty member or a strong background in heading up task forces, your unique strengths will be your strongest argument in negotiating your contract.

“The most effective way to negotiate is to talk about the value-added,” says Dr. McCurdy. “Find out what they want, and speak to that. You’ll have to figure that out as you go.”

It might be what you can do to improve the organization’s bottom line; it might be specific skills or expertise you bring to the table, such as teaching proficiency or research skills.

What about recent graduates who are seeking their first job as a hospitalist? “People right out of training seem to have distinct advantages that they don’t emphasize,” says Dr. McCurdy. “They’re young and have a high energy level, for one thing. Their knowledge base is very current, so they’re cutting edge, and they have quality of training—they were recently instructed by cutting-edge teachers.”

4. Look Beyond Salary

Of course you’ll want to negotiate for as much money as you can, but other factors may make a lower salary worthwhile to you. “Lots of organizations have a lot of non-tangibles to offer, but many physicians go into this ill informed” about what they can get, says Dr. McCurdy. You might ask for “some equity holding in the organization you’re looking to become part of” if it’s a privately held hospital medicine group.

“Think about various trade-offs,” urges Dr. McCurdy. “For example, you might accept a lower salary for less on-call time. Or if you’re considering a position in academic medicine, you know that your residents will take most of your night hours—is that worth a lower salary to you?”

You might also consider “access to a foundation that could help you leverage a project you want to do or a situation where you have a chance to spin off intellectual property where you keep the proceeds,” he suggests. “It all depends on the organization. What do they have that would be valuable to you?”

5. Practice Your Negotiation Skills

One last piece of homework before you walk into the final interview: Do a practice run of how the meeting might go.

Physicians don’t always practice negotiation conversations, says Dr. McCurdy. “Find someone who will practice with you, who will throw a lot of questions at you. I used a personal coach. She had me practicing ‘how to deal with Fred when he’s in conflict.’ I hated it, and I’m so glad I did it!”

So do your homework and be prepared to argue your strengths, stick up for your non-negotiables, and resign yourself to giving in on some of your other points. With insight, information, and practice, you’ll be in an excellent position to walk away from the table with most—if not all—of what you want in your next contract. TH

Jane Jerrard writes “Career Management” monthly for The Hospitalist.

A63-year-old female with a history of hypertension and nicotine dependence presented with acute substernal chest pain. The patient reported that the pain was a dull pressure, 5/10 in severity, which radiated into her neck and left arm and was associated with dyspnea.

The patient was on atenolol for hypertension. She reported a 30-year smoking history. A physical exam revealed an anxious, hypertensive (180/95), tachycardic (123 bpm) female. Findings on cardiovascular exam were otherwise unremarkable. Electrocardiogram revealed a 2-3 mm ST-segment elevation in leads V2-V6. Laboratory tests revealed an elevated troponin T level (0.32 ng/mL [nl < 0.03 ng/mL]) and an elevated creatinine kinase-MB fraction (8.2 ng/mL [nl < 6.2 ng/mL]).

Using the above information, the diagnosis of an ST-segment elevation MI was made. The patient went in for urgent cardiac catheterization, which revealed normal coronary anatomy. A left ventriculogram demonstrated moderate hypokinesis of the apical segment and a left ventricular ejection fraction of 34%. TH

This patient’s symptoms are caused by left ventricular apical ballooning syndrome.

What is the most likely cause of the patient’s ECG changes, elevated cardiac biomarkers, and reduced left ventricular function?

1. Left ventricular aneurysm
2. ST-segment elevation myocardial infarction
3. Left ventricular apical ballooning syndrome
4. Myocarditis
5. Amyloidosis

Discussion

The answer is C: left ventricular apical ballooning syndrome. Transient left ventricular apical ballooning syndrome is a recently described cardiac condition that mimics the clinical presentation of atherosclerotic acute coronary syndrome. Also known as Takotsubo cardiomyopathy, after a round-bottomed, narrow-necked Japanese fishing pot used for trapping octopus, transient left ventricular apical ballooning syndrome was first described in Japan by Dote and colleagues more than a decade ago.1

Typical findings include patients with ischemia-like chest pain and dyspnea, ST-segment elevation and evolutionary T-wave inversion noted on ECG, mildly elevated levels of cardiac biomarkers, and transient apical wall motion abnormalities. These findings occur in the absence of obstructive coronary atherosclerosis. The condition is predominantly seen in postmenopausal women, and most episodes occur after an event causing physical or emotional stress.

The etiology of this condition is widely debated. Many feel that an exaggerated sympathetic response is the critical mechanism of this syndrome. One study has shown that patients with this syndrome had supraphysiologic levels of plasma catecholamines and stress-related neuropeptides.

Treatment is mainly supportive once ST-segment elevation myocardial infarction has been ruled out with a coronary angiogram. Beta-blocker therapy may be appropriate due to presumed catecholamine surge. Short-term cardiac monitoring is also prudent to evaluate for dysrhythmia. Finally, anticoagulation may be considered to prevent mural thrombosis formation.

The prognosis for patients with transient left ventricular apical ballooning syndrome is favorable, with most patients regaining normal systolic ventricular function within several months, and recurrence is rare. Follow-up echocardiographic evaluation is commonly conducted to ensure adequate resolution of systolic left ventricular dysfunction.

Universal diagnostic criteria for transient left ventricular apical ballooning syndrome have not been established. One diagnostic algorithm recently published includes four criteria: 1) transient regional wall motion abnormalities of the left ventricular apical and midventricular segments; 2) absence of obstructive coronary disease or plaque rupture; 3) new ST-segment elevation and/or T-wave inversion; and 4) absence of an obvious alternative cause (e.g., recent head trauma, extensive intracranial bleeding, myocarditis, pheochromocytoma, hypertrophic cardiomyopathy). To make the diagnosis of transient left ventricular apical ballooning syndrome, all four criteria must be met.

As awareness of transient left ventricular apical ballooning syndrome increases, and as evaluation of left ventricular function becomes standard, this diagnosis is becoming more common. In patients presenting with ST-segment elevation and suspected acute coronary syndromes, one must keep apical ballooning syndrome in the differential. Prompt recognition and aggressive supportive treatment are indicated, and recovery of systolic function can be expected. TH

References

1. Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases [in Japanese]. J Cardiol. 1991;21(2):203-214.

A63-year-old female with a history of hypertension and nicotine dependence presented with acute substernal chest pain. The patient reported that the pain was a dull pressure, 5/10 in severity, which radiated into her neck and left arm and was associated with dyspnea.

The patient was on atenolol for hypertension. She reported a 30-year smoking history. A physical exam revealed an anxious, hypertensive (180/95), tachycardic (123 bpm) female. Findings on cardiovascular exam were otherwise unremarkable. Electrocardiogram revealed a 2-3 mm ST-segment elevation in leads V2-V6. Laboratory tests revealed an elevated troponin T level (0.32 ng/mL [nl < 0.03 ng/mL]) and an elevated creatinine kinase-MB fraction (8.2 ng/mL [nl < 6.2 ng/mL]).

Using the above information, the diagnosis of an ST-segment elevation MI was made. The patient went in for urgent cardiac catheterization, which revealed normal coronary anatomy. A left ventriculogram demonstrated moderate hypokinesis of the apical segment and a left ventricular ejection fraction of 34%. TH

This patient’s symptoms are caused by left ventricular apical ballooning syndrome.

What is the most likely cause of the patient’s ECG changes, elevated cardiac biomarkers, and reduced left ventricular function?

1. Left ventricular aneurysm
2. ST-segment elevation myocardial infarction
3. Left ventricular apical ballooning syndrome
4. Myocarditis
5. Amyloidosis

Discussion

The answer is C: left ventricular apical ballooning syndrome. Transient left ventricular apical ballooning syndrome is a recently described cardiac condition that mimics the clinical presentation of atherosclerotic acute coronary syndrome. Also known as Takotsubo cardiomyopathy, after a round-bottomed, narrow-necked Japanese fishing pot used for trapping octopus, transient left ventricular apical ballooning syndrome was first described in Japan by Dote and colleagues more than a decade ago.1

Typical findings include patients with ischemia-like chest pain and dyspnea, ST-segment elevation and evolutionary T-wave inversion noted on ECG, mildly elevated levels of cardiac biomarkers, and transient apical wall motion abnormalities. These findings occur in the absence of obstructive coronary atherosclerosis. The condition is predominantly seen in postmenopausal women, and most episodes occur after an event causing physical or emotional stress.

The etiology of this condition is widely debated. Many feel that an exaggerated sympathetic response is the critical mechanism of this syndrome. One study has shown that patients with this syndrome had supraphysiologic levels of plasma catecholamines and stress-related neuropeptides.

Treatment is mainly supportive once ST-segment elevation myocardial infarction has been ruled out with a coronary angiogram. Beta-blocker therapy may be appropriate due to presumed catecholamine surge. Short-term cardiac monitoring is also prudent to evaluate for dysrhythmia. Finally, anticoagulation may be considered to prevent mural thrombosis formation.

The prognosis for patients with transient left ventricular apical ballooning syndrome is favorable, with most patients regaining normal systolic ventricular function within several months, and recurrence is rare. Follow-up echocardiographic evaluation is commonly conducted to ensure adequate resolution of systolic left ventricular dysfunction.

Universal diagnostic criteria for transient left ventricular apical ballooning syndrome have not been established. One diagnostic algorithm recently published includes four criteria: 1) transient regional wall motion abnormalities of the left ventricular apical and midventricular segments; 2) absence of obstructive coronary disease or plaque rupture; 3) new ST-segment elevation and/or T-wave inversion; and 4) absence of an obvious alternative cause (e.g., recent head trauma, extensive intracranial bleeding, myocarditis, pheochromocytoma, hypertrophic cardiomyopathy). To make the diagnosis of transient left ventricular apical ballooning syndrome, all four criteria must be met.

As awareness of transient left ventricular apical ballooning syndrome increases, and as evaluation of left ventricular function becomes standard, this diagnosis is becoming more common. In patients presenting with ST-segment elevation and suspected acute coronary syndromes, one must keep apical ballooning syndrome in the differential. Prompt recognition and aggressive supportive treatment are indicated, and recovery of systolic function can be expected. TH

References

1. Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases [in Japanese]. J Cardiol. 1991;21(2):203-214.

A63-year-old female with a history of hypertension and nicotine dependence presented with acute substernal chest pain. The patient reported that the pain was a dull pressure, 5/10 in severity, which radiated into her neck and left arm and was associated with dyspnea.

The patient was on atenolol for hypertension. She reported a 30-year smoking history. A physical exam revealed an anxious, hypertensive (180/95), tachycardic (123 bpm) female. Findings on cardiovascular exam were otherwise unremarkable. Electrocardiogram revealed a 2-3 mm ST-segment elevation in leads V2-V6. Laboratory tests revealed an elevated troponin T level (0.32 ng/mL [nl < 0.03 ng/mL]) and an elevated creatinine kinase-MB fraction (8.2 ng/mL [nl < 6.2 ng/mL]).

Using the above information, the diagnosis of an ST-segment elevation MI was made. The patient went in for urgent cardiac catheterization, which revealed normal coronary anatomy. A left ventriculogram demonstrated moderate hypokinesis of the apical segment and a left ventricular ejection fraction of 34%. TH

This patient’s symptoms are caused by left ventricular apical ballooning syndrome.

What is the most likely cause of the patient’s ECG changes, elevated cardiac biomarkers, and reduced left ventricular function?

1. Left ventricular aneurysm
2. ST-segment elevation myocardial infarction
3. Left ventricular apical ballooning syndrome
4. Myocarditis
5. Amyloidosis

Discussion

The answer is C: left ventricular apical ballooning syndrome. Transient left ventricular apical ballooning syndrome is a recently described cardiac condition that mimics the clinical presentation of atherosclerotic acute coronary syndrome. Also known as Takotsubo cardiomyopathy, after a round-bottomed, narrow-necked Japanese fishing pot used for trapping octopus, transient left ventricular apical ballooning syndrome was first described in Japan by Dote and colleagues more than a decade ago.1

Typical findings include patients with ischemia-like chest pain and dyspnea, ST-segment elevation and evolutionary T-wave inversion noted on ECG, mildly elevated levels of cardiac biomarkers, and transient apical wall motion abnormalities. These findings occur in the absence of obstructive coronary atherosclerosis. The condition is predominantly seen in postmenopausal women, and most episodes occur after an event causing physical or emotional stress.

The etiology of this condition is widely debated. Many feel that an exaggerated sympathetic response is the critical mechanism of this syndrome. One study has shown that patients with this syndrome had supraphysiologic levels of plasma catecholamines and stress-related neuropeptides.

Treatment is mainly supportive once ST-segment elevation myocardial infarction has been ruled out with a coronary angiogram. Beta-blocker therapy may be appropriate due to presumed catecholamine surge. Short-term cardiac monitoring is also prudent to evaluate for dysrhythmia. Finally, anticoagulation may be considered to prevent mural thrombosis formation.

The prognosis for patients with transient left ventricular apical ballooning syndrome is favorable, with most patients regaining normal systolic ventricular function within several months, and recurrence is rare. Follow-up echocardiographic evaluation is commonly conducted to ensure adequate resolution of systolic left ventricular dysfunction.

Universal diagnostic criteria for transient left ventricular apical ballooning syndrome have not been established. One diagnostic algorithm recently published includes four criteria: 1) transient regional wall motion abnormalities of the left ventricular apical and midventricular segments; 2) absence of obstructive coronary disease or plaque rupture; 3) new ST-segment elevation and/or T-wave inversion; and 4) absence of an obvious alternative cause (e.g., recent head trauma, extensive intracranial bleeding, myocarditis, pheochromocytoma, hypertrophic cardiomyopathy). To make the diagnosis of transient left ventricular apical ballooning syndrome, all four criteria must be met.

As awareness of transient left ventricular apical ballooning syndrome increases, and as evaluation of left ventricular function becomes standard, this diagnosis is becoming more common. In patients presenting with ST-segment elevation and suspected acute coronary syndromes, one must keep apical ballooning syndrome in the differential. Prompt recognition and aggressive supportive treatment are indicated, and recovery of systolic function can be expected. TH

References

1. Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases [in Japanese]. J Cardiol. 1991;21(2):203-214.

Heart failure (HF) afflicts almost 5 million individuals in the United States and ranks among the most costly inpatient conditions, with hospital costs for 2004 estimated between $14 and $20 billion. Approximately 25% of heart failure patients are readmitted within 30 days of hospital discharge, and more than 50% of elderly patients with HF are readmitted to the hospital within six months. SHM believes that hospitalists are well positioned to improve adherence to published guidelines for the care of congestive HF and are ideal candidates for developing and studying strategies for providing safer, more effective care for patients hospitalized with HF.

In May 2005, SHM disseminated a request for applications for the Heart Failure Research Program. The program, which was made possible by an unrestricted educational grant from Scios, Inc. (a biopharmaceutical company), offered two-year grants to support prospective evaluations of hospitalist-led initiatives designed to improve quality of care for patients hospitalized with HF. A 15-member scientific review group, chaired by Andrew Auerbach, MD, and convened in conjunction with the SHM Research Committee and the SHM Executive Board, reviewed the 18 submitted applications and selected two excellent studies for funding.

The Cardiology Quality of Care Study is a collaborative effort between the sections of General Internal Medicine and Cardiology and the University of Chicago Hospitals. Under the direction of principal investigator Chad Whelan, MD, the study team will evaluate a cost-effective system of improving compliance with the well-validated Centers for Medicare and Medicaid Services (CMS) quality indicators for HF. Trained research assistants will perform chart reviews on all hospitalized patients with HF. If a chart review reveals that certain CMS measures have not been met, the research assistant will send a notification e-mail to the clinical team to alert them that a potentially indicated therapy has not been implemented. Follow-up telephone interviews with patients and post-discharge hospital chart abstractions will be used to evaluate the effectiveness of the intervention. The process may be an effective and inexpensive method for hospitals across the country to use to improve compliance with evidence-based, guideline-supported quality of care measures.

The second study, Improving Quality and Efficiency of Heart Failure Care at Hospital Discharge, is being conducted at the Cleveland Clinic Foundation under the direction of Dr. Christopher Phillips. This single-center, randomized, controlled trial will study changes in 30-day readmission rates resulting from an educational intervention designed to enhance self-care behavior in patients discharged with a primary diagnosis of HF. An RN cardiovascular specialist will contact patients weekly by phone for four weeks after hospital discharge. The calls will focus on identifying and correcting deficits in knowledge, motivation, and behavior with respect to HF self-care. Study findings may improve our understanding of patients’ ability to translate HF education and counseling into motivation to adhere to recommended HF self-care behaviors during the post-discharge period. Improved insight into these processes will inform efforts aimed at optimizing the transition from acute hospital care to home, a process that is a major determinant of early readmission.

Both studies are evaluating novel, practical, reproducible means of improving HF care. We look forward to seeing the results. TH

Heart failure (HF) afflicts almost 5 million individuals in the United States and ranks among the most costly inpatient conditions, with hospital costs for 2004 estimated between $14 and $20 billion. Approximately 25% of heart failure patients are readmitted within 30 days of hospital discharge, and more than 50% of elderly patients with HF are readmitted to the hospital within six months. SHM believes that hospitalists are well positioned to improve adherence to published guidelines for the care of congestive HF and are ideal candidates for developing and studying strategies for providing safer, more effective care for patients hospitalized with HF.

In May 2005, SHM disseminated a request for applications for the Heart Failure Research Program. The program, which was made possible by an unrestricted educational grant from Scios, Inc. (a biopharmaceutical company), offered two-year grants to support prospective evaluations of hospitalist-led initiatives designed to improve quality of care for patients hospitalized with HF. A 15-member scientific review group, chaired by Andrew Auerbach, MD, and convened in conjunction with the SHM Research Committee and the SHM Executive Board, reviewed the 18 submitted applications and selected two excellent studies for funding.

The Cardiology Quality of Care Study is a collaborative effort between the sections of General Internal Medicine and Cardiology and the University of Chicago Hospitals. Under the direction of principal investigator Chad Whelan, MD, the study team will evaluate a cost-effective system of improving compliance with the well-validated Centers for Medicare and Medicaid Services (CMS) quality indicators for HF. Trained research assistants will perform chart reviews on all hospitalized patients with HF. If a chart review reveals that certain CMS measures have not been met, the research assistant will send a notification e-mail to the clinical team to alert them that a potentially indicated therapy has not been implemented. Follow-up telephone interviews with patients and post-discharge hospital chart abstractions will be used to evaluate the effectiveness of the intervention. The process may be an effective and inexpensive method for hospitals across the country to use to improve compliance with evidence-based, guideline-supported quality of care measures.

The second study, Improving Quality and Efficiency of Heart Failure Care at Hospital Discharge, is being conducted at the Cleveland Clinic Foundation under the direction of Dr. Christopher Phillips. This single-center, randomized, controlled trial will study changes in 30-day readmission rates resulting from an educational intervention designed to enhance self-care behavior in patients discharged with a primary diagnosis of HF. An RN cardiovascular specialist will contact patients weekly by phone for four weeks after hospital discharge. The calls will focus on identifying and correcting deficits in knowledge, motivation, and behavior with respect to HF self-care. Study findings may improve our understanding of patients’ ability to translate HF education and counseling into motivation to adhere to recommended HF self-care behaviors during the post-discharge period. Improved insight into these processes will inform efforts aimed at optimizing the transition from acute hospital care to home, a process that is a major determinant of early readmission.

Both studies are evaluating novel, practical, reproducible means of improving HF care. We look forward to seeing the results. TH

Heart failure (HF) afflicts almost 5 million individuals in the United States and ranks among the most costly inpatient conditions, with hospital costs for 2004 estimated between $14 and $20 billion. Approximately 25% of heart failure patients are readmitted within 30 days of hospital discharge, and more than 50% of elderly patients with HF are readmitted to the hospital within six months. SHM believes that hospitalists are well positioned to improve adherence to published guidelines for the care of congestive HF and are ideal candidates for developing and studying strategies for providing safer, more effective care for patients hospitalized with HF.

In May 2005, SHM disseminated a request for applications for the Heart Failure Research Program. The program, which was made possible by an unrestricted educational grant from Scios, Inc. (a biopharmaceutical company), offered two-year grants to support prospective evaluations of hospitalist-led initiatives designed to improve quality of care for patients hospitalized with HF. A 15-member scientific review group, chaired by Andrew Auerbach, MD, and convened in conjunction with the SHM Research Committee and the SHM Executive Board, reviewed the 18 submitted applications and selected two excellent studies for funding.

The Cardiology Quality of Care Study is a collaborative effort between the sections of General Internal Medicine and Cardiology and the University of Chicago Hospitals. Under the direction of principal investigator Chad Whelan, MD, the study team will evaluate a cost-effective system of improving compliance with the well-validated Centers for Medicare and Medicaid Services (CMS) quality indicators for HF. Trained research assistants will perform chart reviews on all hospitalized patients with HF. If a chart review reveals that certain CMS measures have not been met, the research assistant will send a notification e-mail to the clinical team to alert them that a potentially indicated therapy has not been implemented. Follow-up telephone interviews with patients and post-discharge hospital chart abstractions will be used to evaluate the effectiveness of the intervention. The process may be an effective and inexpensive method for hospitals across the country to use to improve compliance with evidence-based, guideline-supported quality of care measures.

The second study, Improving Quality and Efficiency of Heart Failure Care at Hospital Discharge, is being conducted at the Cleveland Clinic Foundation under the direction of Dr. Christopher Phillips. This single-center, randomized, controlled trial will study changes in 30-day readmission rates resulting from an educational intervention designed to enhance self-care behavior in patients discharged with a primary diagnosis of HF. An RN cardiovascular specialist will contact patients weekly by phone for four weeks after hospital discharge. The calls will focus on identifying and correcting deficits in knowledge, motivation, and behavior with respect to HF self-care. Study findings may improve our understanding of patients’ ability to translate HF education and counseling into motivation to adhere to recommended HF self-care behaviors during the post-discharge period. Improved insight into these processes will inform efforts aimed at optimizing the transition from acute hospital care to home, a process that is a major determinant of early readmission.

Both studies are evaluating novel, practical, reproducible means of improving HF care. We look forward to seeing the results. TH

SHM intensified its advocacy efforts over the past several months in support of proposed changes to the Medicare physician fee schedule that would significantly increase payments to hospitalists for many services next year, if adopted by the Centers for Medicare and Medicaid Services (CMS). In June, CMS proposed to make the largest increase in the work relative value units (RVUs) assigned to evaluation and management (E/M) services since Medicare implemented the physician fee schedule in 1992. E/M codes, which represent the time and effort that physicians spend to evaluate patient conditions, have long been viewed as undervalued. Since the release of the proposed rule, SHM has voiced its strong support for CMS’ proposed changes. (See “Calculating the Future of Medicare Payments,” Oct., p. 1).

In an August 18 letter, SHM joined the American College of Physicians (ACP) and 12 other physician groups in urging CMS Administrator Mark McClellan, MD, to include in the final rule the proposed increases in the RVUs assigned to office and hospital visits, and consultations. The groups applauded CMS’ decision to accept the recommendations made by the AMA Relative Value Scale Update Committee (RUC) regarding the evaluation and management codes under the five-year review. “We support the decision to include them in this proposed rule and we strongly urge CMS to include the same proposed work relative value units (RVUs) in the final rule,” the letter stated.

The RUC was careful to ensure that these codes went through the standard survey process and that the data supporting the changes was very strong. The letter emphasized: “The RUC approval of these recommendations, which requires support from at least two-thirds of the RUC members, indicates wide recognition of the work changes in evaluation and management in the 10 years since CMS last reviewed the codes. During our investigation into the increased intensity of evaluation and management services and throughout the RUC process for determining accurate, current work RVUs, we became increasingly aware that enormous changes in patient and physician practice characteristics necessitated these changes.”

In addition, the letter urged CMS to make the required budget neutrality adjustments that result from the five-year review to the conversion factor rather than by an adjustment to the work RVUs. CMS is required by law to offset increases in costs with a mandatory adjustment to keep 2007 expenditures roughly equal to their 2006 level. In the proposed rule, the agency recommended cutting work RVUs by 10% in order to achieve budget neutrality.

SHM joined the AMA and more than 70 other physician organizations in a separate letter. That letter asked CMS not to apply a 10% cut to the work component of the fee schedule, but instead to make an adjustment to the Medicare conversion factor.

“Applying budget neutrality to the work RVUs to offset the improvements in E/M and other services is a step backward and we strongly urge CMS to instead apply any necessary adjustments to the conversion factor,” the organizations said in an August 21 letter to CMS.

When the agency reduced the work RVUs in the past, it created confusion among private insurers, the letter said. Since 1998, similar reductions have been applied to the conversion factor. “CMS does not explain why it proposes to alter this long utilized method and move backward to an approach that the agency itself remarked was inappropriate.”

SHM and the physician community have also lobbied Congress to block a 5.1% cut in the Medicare physician fee schedule that will take effect on January 1, 2007, unless lawmakers take action this fall.

For more news on the five-year review, the 2007 update, and other issues, visit the advocacy and policy section of the SHM Web site at www.hospitalmedicine.org.

Allendorf is senior advisor of Advocacy and Government Affairs for SHM.

SHM intensified its advocacy efforts over the past several months in support of proposed changes to the Medicare physician fee schedule that would significantly increase payments to hospitalists for many services next year, if adopted by the Centers for Medicare and Medicaid Services (CMS). In June, CMS proposed to make the largest increase in the work relative value units (RVUs) assigned to evaluation and management (E/M) services since Medicare implemented the physician fee schedule in 1992. E/M codes, which represent the time and effort that physicians spend to evaluate patient conditions, have long been viewed as undervalued. Since the release of the proposed rule, SHM has voiced its strong support for CMS’ proposed changes. (See “Calculating the Future of Medicare Payments,” Oct., p. 1).

In an August 18 letter, SHM joined the American College of Physicians (ACP) and 12 other physician groups in urging CMS Administrator Mark McClellan, MD, to include in the final rule the proposed increases in the RVUs assigned to office and hospital visits, and consultations. The groups applauded CMS’ decision to accept the recommendations made by the AMA Relative Value Scale Update Committee (RUC) regarding the evaluation and management codes under the five-year review. “We support the decision to include them in this proposed rule and we strongly urge CMS to include the same proposed work relative value units (RVUs) in the final rule,” the letter stated.

The RUC was careful to ensure that these codes went through the standard survey process and that the data supporting the changes was very strong. The letter emphasized: “The RUC approval of these recommendations, which requires support from at least two-thirds of the RUC members, indicates wide recognition of the work changes in evaluation and management in the 10 years since CMS last reviewed the codes. During our investigation into the increased intensity of evaluation and management services and throughout the RUC process for determining accurate, current work RVUs, we became increasingly aware that enormous changes in patient and physician practice characteristics necessitated these changes.”

In addition, the letter urged CMS to make the required budget neutrality adjustments that result from the five-year review to the conversion factor rather than by an adjustment to the work RVUs. CMS is required by law to offset increases in costs with a mandatory adjustment to keep 2007 expenditures roughly equal to their 2006 level. In the proposed rule, the agency recommended cutting work RVUs by 10% in order to achieve budget neutrality.

SHM joined the AMA and more than 70 other physician organizations in a separate letter. That letter asked CMS not to apply a 10% cut to the work component of the fee schedule, but instead to make an adjustment to the Medicare conversion factor.

“Applying budget neutrality to the work RVUs to offset the improvements in E/M and other services is a step backward and we strongly urge CMS to instead apply any necessary adjustments to the conversion factor,” the organizations said in an August 21 letter to CMS.

When the agency reduced the work RVUs in the past, it created confusion among private insurers, the letter said. Since 1998, similar reductions have been applied to the conversion factor. “CMS does not explain why it proposes to alter this long utilized method and move backward to an approach that the agency itself remarked was inappropriate.”

SHM and the physician community have also lobbied Congress to block a 5.1% cut in the Medicare physician fee schedule that will take effect on January 1, 2007, unless lawmakers take action this fall.

For more news on the five-year review, the 2007 update, and other issues, visit the advocacy and policy section of the SHM Web site at www.hospitalmedicine.org.

Allendorf is senior advisor of Advocacy and Government Affairs for SHM.

SHM intensified its advocacy efforts over the past several months in support of proposed changes to the Medicare physician fee schedule that would significantly increase payments to hospitalists for many services next year, if adopted by the Centers for Medicare and Medicaid Services (CMS). In June, CMS proposed to make the largest increase in the work relative value units (RVUs) assigned to evaluation and management (E/M) services since Medicare implemented the physician fee schedule in 1992. E/M codes, which represent the time and effort that physicians spend to evaluate patient conditions, have long been viewed as undervalued. Since the release of the proposed rule, SHM has voiced its strong support for CMS’ proposed changes. (See “Calculating the Future of Medicare Payments,” Oct., p. 1).

In an August 18 letter, SHM joined the American College of Physicians (ACP) and 12 other physician groups in urging CMS Administrator Mark McClellan, MD, to include in the final rule the proposed increases in the RVUs assigned to office and hospital visits, and consultations. The groups applauded CMS’ decision to accept the recommendations made by the AMA Relative Value Scale Update Committee (RUC) regarding the evaluation and management codes under the five-year review. “We support the decision to include them in this proposed rule and we strongly urge CMS to include the same proposed work relative value units (RVUs) in the final rule,” the letter stated.

The RUC was careful to ensure that these codes went through the standard survey process and that the data supporting the changes was very strong. The letter emphasized: “The RUC approval of these recommendations, which requires support from at least two-thirds of the RUC members, indicates wide recognition of the work changes in evaluation and management in the 10 years since CMS last reviewed the codes. During our investigation into the increased intensity of evaluation and management services and throughout the RUC process for determining accurate, current work RVUs, we became increasingly aware that enormous changes in patient and physician practice characteristics necessitated these changes.”

In addition, the letter urged CMS to make the required budget neutrality adjustments that result from the five-year review to the conversion factor rather than by an adjustment to the work RVUs. CMS is required by law to offset increases in costs with a mandatory adjustment to keep 2007 expenditures roughly equal to their 2006 level. In the proposed rule, the agency recommended cutting work RVUs by 10% in order to achieve budget neutrality.

SHM joined the AMA and more than 70 other physician organizations in a separate letter. That letter asked CMS not to apply a 10% cut to the work component of the fee schedule, but instead to make an adjustment to the Medicare conversion factor.

“Applying budget neutrality to the work RVUs to offset the improvements in E/M and other services is a step backward and we strongly urge CMS to instead apply any necessary adjustments to the conversion factor,” the organizations said in an August 21 letter to CMS.

When the agency reduced the work RVUs in the past, it created confusion among private insurers, the letter said. Since 1998, similar reductions have been applied to the conversion factor. “CMS does not explain why it proposes to alter this long utilized method and move backward to an approach that the agency itself remarked was inappropriate.”

SHM and the physician community have also lobbied Congress to block a 5.1% cut in the Medicare physician fee schedule that will take effect on January 1, 2007, unless lawmakers take action this fall.

For more news on the five-year review, the 2007 update, and other issues, visit the advocacy and policy section of the SHM Web site at www.hospitalmedicine.org.

Allendorf is senior advisor of Advocacy and Government Affairs for SHM.

I joined SHM earlier this year to work with SHM’s Membership and Marketing staff. My role at SHM is to manage our growing organization’s communications. So what does that mean in real terms? Most importantly, we have been tasked with understanding what is important to our members and what value SHM membership needs to provide to you. We’re also working to build a strong foundation for the SHM brand, so keep an eye out for an updated, consistent look to our communications—both online and off.

Feedback from our members and the hospital medicine community at large is vital to us. Samuel Johnson (1709-1764), an often-quoted English writer, once said, “The next best thing to knowing something is knowing where to find it.” One common thread among those I have talked to over the past few months has been concern that although our Web site is comprehensive, finding specific information can be challenging. Quickly making the Web site user-friendly became a priority and, along with our resident Web design guru Bruce Hansen, we have created a navigation system designed to get you to our site’s most popular information in the fewest number of clicks.

Looking for a link to the Journal of Hospital Medicine pages? The Hospitalist Web site? Our new Career Center? Or our Resource Rooms? Look no further than the top of our homepage (www.hospitalmedicine.org). Our new clickable banner will get you where you need to go in no time.

In a few short clicks, you can read pages from the Journal, including expert articles by leading practitioners on current and future trends in hospital medicine. Surf over to The Hospitalist Web site for the latest issue of our monthly newsmagazine. Have a story idea or want to contact the editor? You can do it all on The Hospitalist Web site.

Find your first or next hospitalist job at our new SHM Career Center. This one-of-a-kind forum for those looking for jobs and those with positions to fill helps you to avoid the excess of other career sites by focusing on our specific industry. Our Resource Rooms provide you with access to expert advice and information on every aspect of your practice. We’ve got the tools you need, and our Resource Rooms are the toolbox.

Of course, we hope you won’t forget the rest of our Web site: Look for the latest in advocacy and policy updates, our online discussion communities, and breaking news in the field of hospital medicine.

We hope you will set aside a few minutes each month to review our revamped SHM eNewsletter. Kudos again to Bruce for its ultra-sleek, contemporary design, which both pleases the eye and improves the readability of the articles. Research has shown us that most people read our articles online, as opposed to printing them out and reading them, so look for larger fonts and a clean layout.

We’ve introduced many new columns that will become a regular part of the SHM eNewsletter, including our Career Center Job of the Month, Clinical News, Advocacy News, upcoming articles from The Hospitalist—and more. We are also proud to introduce our featured product of the month from our newly launched SHM Store. Looking for a way to show your hospitalist pride? Why not grab one of our SHM polo shirts, scrub tops, or a baseball cap? The SHM store also features educational products. Looking for an extra copy of The Core Competencies or the ““Bi-Annual Survey on the State of the Hospital Medicine Movement”? You’ll find them, along with nearly 100 other items, at the SHM Store.

These are just a few of the changes we have made to transform SHM into your organization. Keep watching, and you will find that SHM, ground central for the hospital medicine movement, is the best place to turn for anything and everything relating to hospital medicine.

If you should have any questions or comments, our doors and ears are always open and ready to welcome you. Feel free to give us a call at (800) 843-3360.

Stay tuned for next month’s SHM staff member report from Tina Budnitz, SHM’s senior advisor for quality initiatives.

Sanders is the marketing manager for SHM.

SHM CHAPTER REPORTS

Lake Erie

SHM’s Lake Erie Chapter met at Morton’s Steakhouse in Cleveland on August 9. The guest speaker was Ron J. Kattoo, MD, associate director of intensive care at Henry Ford Hospital and Health System in Detroit. Dr. Kattoo spoke about the management options for healthcare and ventilator-associated pneumonia, followed by a discussion about the role of hospitalists in the management of this severe condition. The meeting was sponsored by Pfizer Pharmaceutical Company. For more information on the Lake Erie Chapter of SHM, please contact Christopher Whinney, MD, at whinnec@ccf.org.

Long Island

SHM’s Long Island (N.Y.) Chapter held a meeting on August 24 at Burton & Doyle Steakhouse in East Great Neck, N.Y. A presentation titled “Sleep Disorders: How They Affect Patients and Providers” was given by Sonia Ancoli-Israel, PhD, a University of California at San Diego School of Medicine professor of psychiatry. At the conclusion of the presentation, Dr. Ancoli-Israel fielded questions.

I joined SHM earlier this year to work with SHM’s Membership and Marketing staff. My role at SHM is to manage our growing organization’s communications. So what does that mean in real terms? Most importantly, we have been tasked with understanding what is important to our members and what value SHM membership needs to provide to you. We’re also working to build a strong foundation for the SHM brand, so keep an eye out for an updated, consistent look to our communications—both online and off.

Feedback from our members and the hospital medicine community at large is vital to us. Samuel Johnson (1709-1764), an often-quoted English writer, once said, “The next best thing to knowing something is knowing where to find it.” One common thread among those I have talked to over the past few months has been concern that although our Web site is comprehensive, finding specific information can be challenging. Quickly making the Web site user-friendly became a priority and, along with our resident Web design guru Bruce Hansen, we have created a navigation system designed to get you to our site’s most popular information in the fewest number of clicks.

Looking for a link to the Journal of Hospital Medicine pages? The Hospitalist Web site? Our new Career Center? Or our Resource Rooms? Look no further than the top of our homepage (www.hospitalmedicine.org). Our new clickable banner will get you where you need to go in no time.

In a few short clicks, you can read pages from the Journal, including expert articles by leading practitioners on current and future trends in hospital medicine. Surf over to The Hospitalist Web site for the latest issue of our monthly newsmagazine. Have a story idea or want to contact the editor? You can do it all on The Hospitalist Web site.

Find your first or next hospitalist job at our new SHM Career Center. This one-of-a-kind forum for those looking for jobs and those with positions to fill helps you to avoid the excess of other career sites by focusing on our specific industry. Our Resource Rooms provide you with access to expert advice and information on every aspect of your practice. We’ve got the tools you need, and our Resource Rooms are the toolbox.

Of course, we hope you won’t forget the rest of our Web site: Look for the latest in advocacy and policy updates, our online discussion communities, and breaking news in the field of hospital medicine.

We hope you will set aside a few minutes each month to review our revamped SHM eNewsletter. Kudos again to Bruce for its ultra-sleek, contemporary design, which both pleases the eye and improves the readability of the articles. Research has shown us that most people read our articles online, as opposed to printing them out and reading them, so look for larger fonts and a clean layout.

We’ve introduced many new columns that will become a regular part of the SHM eNewsletter, including our Career Center Job of the Month, Clinical News, Advocacy News, upcoming articles from The Hospitalist—and more. We are also proud to introduce our featured product of the month from our newly launched SHM Store. Looking for a way to show your hospitalist pride? Why not grab one of our SHM polo shirts, scrub tops, or a baseball cap? The SHM store also features educational products. Looking for an extra copy of The Core Competencies or the ““Bi-Annual Survey on the State of the Hospital Medicine Movement”? You’ll find them, along with nearly 100 other items, at the SHM Store.

These are just a few of the changes we have made to transform SHM into your organization. Keep watching, and you will find that SHM, ground central for the hospital medicine movement, is the best place to turn for anything and everything relating to hospital medicine.

If you should have any questions or comments, our doors and ears are always open and ready to welcome you. Feel free to give us a call at (800) 843-3360.

Stay tuned for next month’s SHM staff member report from Tina Budnitz, SHM’s senior advisor for quality initiatives.

Sanders is the marketing manager for SHM.

SHM CHAPTER REPORTS

Lake Erie

SHM’s Lake Erie Chapter met at Morton’s Steakhouse in Cleveland on August 9. The guest speaker was Ron J. Kattoo, MD, associate director of intensive care at Henry Ford Hospital and Health System in Detroit. Dr. Kattoo spoke about the management options for healthcare and ventilator-associated pneumonia, followed by a discussion about the role of hospitalists in the management of this severe condition. The meeting was sponsored by Pfizer Pharmaceutical Company. For more information on the Lake Erie Chapter of SHM, please contact Christopher Whinney, MD, at whinnec@ccf.org.

Long Island

SHM’s Long Island (N.Y.) Chapter held a meeting on August 24 at Burton & Doyle Steakhouse in East Great Neck, N.Y. A presentation titled “Sleep Disorders: How They Affect Patients and Providers” was given by Sonia Ancoli-Israel, PhD, a University of California at San Diego School of Medicine professor of psychiatry. At the conclusion of the presentation, Dr. Ancoli-Israel fielded questions.

I joined SHM earlier this year to work with SHM’s Membership and Marketing staff. My role at SHM is to manage our growing organization’s communications. So what does that mean in real terms? Most importantly, we have been tasked with understanding what is important to our members and what value SHM membership needs to provide to you. We’re also working to build a strong foundation for the SHM brand, so keep an eye out for an updated, consistent look to our communications—both online and off.

Feedback from our members and the hospital medicine community at large is vital to us. Samuel Johnson (1709-1764), an often-quoted English writer, once said, “The next best thing to knowing something is knowing where to find it.” One common thread among those I have talked to over the past few months has been concern that although our Web site is comprehensive, finding specific information can be challenging. Quickly making the Web site user-friendly became a priority and, along with our resident Web design guru Bruce Hansen, we have created a navigation system designed to get you to our site’s most popular information in the fewest number of clicks.

Looking for a link to the Journal of Hospital Medicine pages? The Hospitalist Web site? Our new Career Center? Or our Resource Rooms? Look no further than the top of our homepage (www.hospitalmedicine.org). Our new clickable banner will get you where you need to go in no time.

In a few short clicks, you can read pages from the Journal, including expert articles by leading practitioners on current and future trends in hospital medicine. Surf over to The Hospitalist Web site for the latest issue of our monthly newsmagazine. Have a story idea or want to contact the editor? You can do it all on The Hospitalist Web site.

Find your first or next hospitalist job at our new SHM Career Center. This one-of-a-kind forum for those looking for jobs and those with positions to fill helps you to avoid the excess of other career sites by focusing on our specific industry. Our Resource Rooms provide you with access to expert advice and information on every aspect of your practice. We’ve got the tools you need, and our Resource Rooms are the toolbox.

Of course, we hope you won’t forget the rest of our Web site: Look for the latest in advocacy and policy updates, our online discussion communities, and breaking news in the field of hospital medicine.

We hope you will set aside a few minutes each month to review our revamped SHM eNewsletter. Kudos again to Bruce for its ultra-sleek, contemporary design, which both pleases the eye and improves the readability of the articles. Research has shown us that most people read our articles online, as opposed to printing them out and reading them, so look for larger fonts and a clean layout.

We’ve introduced many new columns that will become a regular part of the SHM eNewsletter, including our Career Center Job of the Month, Clinical News, Advocacy News, upcoming articles from The Hospitalist—and more. We are also proud to introduce our featured product of the month from our newly launched SHM Store. Looking for a way to show your hospitalist pride? Why not grab one of our SHM polo shirts, scrub tops, or a baseball cap? The SHM store also features educational products. Looking for an extra copy of The Core Competencies or the ““Bi-Annual Survey on the State of the Hospital Medicine Movement”? You’ll find them, along with nearly 100 other items, at the SHM Store.

These are just a few of the changes we have made to transform SHM into your organization. Keep watching, and you will find that SHM, ground central for the hospital medicine movement, is the best place to turn for anything and everything relating to hospital medicine.

If you should have any questions or comments, our doors and ears are always open and ready to welcome you. Feel free to give us a call at (800) 843-3360.

Stay tuned for next month’s SHM staff member report from Tina Budnitz, SHM’s senior advisor for quality initiatives.

Sanders is the marketing manager for SHM.

SHM CHAPTER REPORTS

Lake Erie

SHM’s Lake Erie Chapter met at Morton’s Steakhouse in Cleveland on August 9. The guest speaker was Ron J. Kattoo, MD, associate director of intensive care at Henry Ford Hospital and Health System in Detroit. Dr. Kattoo spoke about the management options for healthcare and ventilator-associated pneumonia, followed by a discussion about the role of hospitalists in the management of this severe condition. The meeting was sponsored by Pfizer Pharmaceutical Company. For more information on the Lake Erie Chapter of SHM, please contact Christopher Whinney, MD, at whinnec@ccf.org.

Long Island

SHM’s Long Island (N.Y.) Chapter held a meeting on August 24 at Burton & Doyle Steakhouse in East Great Neck, N.Y. A presentation titled “Sleep Disorders: How They Affect Patients and Providers” was given by Sonia Ancoli-Israel, PhD, a University of California at San Diego School of Medicine professor of psychiatry. At the conclusion of the presentation, Dr. Ancoli-Israel fielded questions.

In the not-too-distant future, a multiphysician hospitalist group is a participant in a pay-for-performance (P4P) program. Dr. Buchmann, the group’s lead hospitalist, is confronted by his hospital’s administration and informed that his doctors are performing below regional benchmarks for standards of care for community-acquired pneumonia, and, in fact, the hospital as a whole is below the mean performance levels.

The hospital threatens to break its contract with Dr. Buchmann’s group despite his response that his group sees a far more complex population than these standards can account for—and besides, his group has implemented a number of important quality initiatives in other diseases that are not part of the P4P program.

Several of the group’s hospitalists state that they will stop seeing indigent patients and will no longer take referrals for high-risk patients. Another partner feels it is unethical to continue treating pneumonia patients at the hospital without informing them of these quality findings and at least offering the option of transfer to a facility with better scores. Dr. Buchmann finds all these propositions unsettling.

While these physicians’ responses may sound extreme, the behavior of physicians caught between the hammer of financial survival and the anvil of professional ethics is unpredictable. Medicare and other payers have been implementing P4P plans as the latest attempt to stimulate quality reform. There are dozens of P4P-based programs operating in the United States, and the financial implications are daunting. Further, P4P is taking hold despite a relative paucity of research regarding its effectiveness in improving outcomes.

The underlying rationale of P4P is the use of economic incentives to stimulate changes in provider behavior. Recent work from the RAND Corporation suggests that as much as one-half of healthcare is not based on “accepted” best practices.1 And with increasing attention on the role of errors in medical practice, any effort to improve care seems, on its surface, laudable.

In general, key elements of P4P programs include a set of performance measures, the collection of data, comparison of provider data with benchmarks, and rewards for physicians who meet or exceed those targets. The interface between economic and financial incentives requires physicians to ensure that their behavior is in line with ethical and professional standards. While journals of medicine, law, and business contain many articles devoted to the policy and market implications of P4P, there is surprisingly little discussion in the literature regarding the potential ethical challenges that physicians may face in these programs.

For hospitalists (and other physicians), P4P may present several troubling ethical issues. Because the current scope of P4P is limited to a few diseases, widespread implementation might lead to relative neglect of patients with other illnesses. Higher-risk patients might be avoided, and individual patient concerns might become subjugated to population performance measures. Hospitalists could face the additional conflict of being accountable to (and/or dependent upon) hospitals, which feel P4P pressures of their own. A final issue is the question of whether shared decision-making and patient-centered care mandate disclosure of non-public quality data to patients.

The American Medical Association (AMA) has a policy that specifically addresses P4P.2 Its “Pay-for-Performance Principles and Guidelines” call for physician participation in P4P to be voluntary and to allow physicians to access their ratings for potential appeal prior to wider release. The policy insists that quality of care be paramount over cost savings and that the physician-patient relationship be preserved. Of course, P4P programs may not share the AMA’s ethical concerns and are not bound to consider them.

Of particular concern—for both inpatient and outpatient physicians—is the fate of high-risk and unassigned patients. According to SHM’s 2005-2006 “Bi-Annual Survey on the State of the Hospital Medicine Movement” (www.hospital medicine.org), 96% of hospitalists are involved in the care of unassigned patients, and, in general, one of the strengths of hospital-based physicians should be their relative familiarity with the acute problems of patients who are older and of those with concomitant morbidities. Yet these are precisely the patient groups that are not well served by typical P4P measurements.

The potential for P4P incentives to create disparities in patient care among different patient groups and diseases is one of the prime concerns in the Council on Ethical and Judicial Affairs’ recent opinion for the AMA on P4P programs.3 The care of older patients, for instance, because of their own choices and due to frequency of comorbidities, may well come up short in performance measures designed for individuals who have a single disease.

This is not just a policy problem because P4P is not only unlikely to adequately address the ethical concerns of equitable care to these groups, it could exacerbate the vulnerability of these populations by creating a disincentive to provide care.4 A recent publication describing reports of cardiac surgeons turning away high-risk patients after “CABG report cards” became publicly available suggests that when given the option at least some physicians may indeed change their behavior when quality information is being collected and reported.5 Ironically, a system that incentivizes doctors to avoid the highest-risk patients could worsen—rather than improve—the overall quality of care.

Hospitalists may not be as sensitive to these pressures as surgeons or outpatient physicians, especially given the hospitalist’s limited flexibility in “choosing” patients. Care of unassigned patients may be a contractual obligation for which a hospitalist is paid by the hospital (which may face its own pressures in this area). And lower-risk referrals from outpatient physicians may “compensate” for the occasional complex patient.

Hospitalists are generally “need-based” practitioners who legally and ethically may not have the option to refuse care without risking patient abandonment. Yet the fact that hospitalists take on such patients may make their performance scores inferior to even non-hospital-based doctors—a difficult position to be in if one’s group receives payments from the hospital with an expectation of superior performance. Hospitalists in particular must consider whether or not insurance companies and the Centers for Medicare and Medicaid Services (CMS) could really accommodate all possible confounders in a risk-adjustment model to offset the nature of their patients. While the ethical choice might be for hospitalists simply to refuse to participate in P4P, citing multiple conflicts of interest, there is no clear indication regarding how “optional” these programs will be as they become increasingly prevalent, presenting yet another ethical issue.

Further, Medicare’s current P4P system for hospitals is directed at just five conditions, only two of which (congestive heart failure and pneumonia) are likely to fall within a hospitalist’s realm. But the list of common diagnoses under the hospitalist’s umbrella is, of course, much larger, including thromboembolism, pyelonephritis, COPD, cirrhosis, and sepsis. The data that exists for compliance with recommended care for some of these conditions (e.g., COPD) suggests that there may be substantial variability.6

But if hospitals base their support for hospitalist programs on their performance within a few CMS diagnoses, the effect on care for and development of appropriate guidelines and resources toward many other conditions may suffer. Already, hospital discharge forms are pre-printed with checkboxes for an angiotensin-converting enzyme (ACE) inhibitor prescription for congestive heart failure and counseling for smoking cessation. The (unethical) implication is that some diagnoses are more valuable than others, and that physician energies may be inequitably distributed—whether consciously or not. It is difficult to see how P4P could encompass standards for every patient condition, or how hospitals and providers could avoid focusing resources on those conditions that are more closely scrutinized by their payers.

Another issue arises if patient autonomy dictates that a treatment plan has to deviate from established guidelines; in such a case, hospitalists and other physicians may be forced to provide a care plan that is entirely reasonable from a medical standpoint but counts against them when compared with a benchmark. Ethical principles dictate that patient care be given priority, but unless consideration is made within the scoring system, performance measures that do not accommodate the ethical mandates to respect patient wishes or physician judgment are substantial pitfalls in the pursuit of better quality.7,8

One last issue concerns the question of whether or not providers have an obligation to disclose quality data to patients in the context of shared decision-making. This is a murky subject that involves determining the boundaries between the best means of pursuing quality improvement and the ethics of patient advocacy. The AMA’s Code of Medical Ethics states, “Patients should receive guidance from their physicians as to the optimal course of action,” and the issue of competence and responsibility to the care of the individual patient is the focus of several of the Principles of Medical Ethics. However, there is practically nothing published regarding the ethics, implications, or results of such disclosure, presumably because the availability of large amounts of quality-based data is such a new phenomenon and the considerations of such disclosure are so uncomfortable for many physicians.

Of course, some information—“CABG report cards,” for instance—is publicly available, but the evidence that patients actually utilize this information to a significant extent or that quality has improved due to its use is mixed.5 The question of whether an obligation exists to disclose non-public information when a provider knows that there is a question about performance relative to a benchmark or comparative peer group is uncharted water, ethically speaking; the issue is further complicated by the fact that appraisal of quality is far from a perfect science. It may be that the benefits of P4P result primarily from transparency, rather than from financial incentives. If so, disclosure may be the major component of quality reform, giving further weight to this question.

The ethical problems raised by P4P are underappreciated and inadequately discussed in the literature, particularly for how rapidly and rampantly these programs are being piloted and implemented. Although the AMA has taken a fairly clear and reasonable stance on the appropriate considerations for P4P programs, it is not clear that payers are incorporating all these concerns. A substantial number of hospitalist groups receive payments from medical groups or hospitals, which in turn are already involved in P4P for some diagnoses.

All hospitalists should read and familiarize themselves with these guidelines and carefully assess the implications of forthcoming P4P proposals for their own practices and patients. On a larger scale, SHM and its membership should strongly consider taking the lead in defining appropriate processes and outcomes for hospital care that incorporate these ethical concerns and allow for meaningful conclusions regarding both quality of care and opportunities for improvement.

Dr. Harte works at the Cleveland Clinic, and Dr. Rajput works at the Robert Wood Johnson Medical School, Camden, N.J. The authors wish to thank Tom Baudendistel and Donald Krause for their review and suggestions.

References

1. Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006 Mar 16;354:1147-1156.
2. American Medical Association. Pay-for-performance principles and guidelines. Accessible at: www.ama-assn.org/meetings/public/annual05/bot5a05.doc. Last accessed September 13, 2006.
3. American Medical Association. CEJA 3-1-05 Report, July 2006. Available at: www.ama-assn.org/ama/pub/category/4325.html. Last accessed September 13, 2006.
4. Morreim EH. Result-based compensation in health care: a good, but limited, idea. J Law Med Ethics. 2001 Summer;29(2):174-181.
5. Werner RM, Asch DA. The unintended consequences of publicly reporting quality information. JAMA. 2005 Mar 9;293:1239-1244.
6. Lindenauer PK, Pekow P, Gao S, et al. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 2006;144(12):894-903.
7. Walter LC, Davidowitz NP, Heineken PA, et al. Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure. JAMA. 2004 May 26;291(20):2466-2470.
8. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005 Aug 10;294(6):716-724.

In the not-too-distant future, a multiphysician hospitalist group is a participant in a pay-for-performance (P4P) program. Dr. Buchmann, the group’s lead hospitalist, is confronted by his hospital’s administration and informed that his doctors are performing below regional benchmarks for standards of care for community-acquired pneumonia, and, in fact, the hospital as a whole is below the mean performance levels.

The hospital threatens to break its contract with Dr. Buchmann’s group despite his response that his group sees a far more complex population than these standards can account for—and besides, his group has implemented a number of important quality initiatives in other diseases that are not part of the P4P program.

Several of the group’s hospitalists state that they will stop seeing indigent patients and will no longer take referrals for high-risk patients. Another partner feels it is unethical to continue treating pneumonia patients at the hospital without informing them of these quality findings and at least offering the option of transfer to a facility with better scores. Dr. Buchmann finds all these propositions unsettling.

While these physicians’ responses may sound extreme, the behavior of physicians caught between the hammer of financial survival and the anvil of professional ethics is unpredictable. Medicare and other payers have been implementing P4P plans as the latest attempt to stimulate quality reform. There are dozens of P4P-based programs operating in the United States, and the financial implications are daunting. Further, P4P is taking hold despite a relative paucity of research regarding its effectiveness in improving outcomes.

The underlying rationale of P4P is the use of economic incentives to stimulate changes in provider behavior. Recent work from the RAND Corporation suggests that as much as one-half of healthcare is not based on “accepted” best practices.1 And with increasing attention on the role of errors in medical practice, any effort to improve care seems, on its surface, laudable.

In general, key elements of P4P programs include a set of performance measures, the collection of data, comparison of provider data with benchmarks, and rewards for physicians who meet or exceed those targets. The interface between economic and financial incentives requires physicians to ensure that their behavior is in line with ethical and professional standards. While journals of medicine, law, and business contain many articles devoted to the policy and market implications of P4P, there is surprisingly little discussion in the literature regarding the potential ethical challenges that physicians may face in these programs.

For hospitalists (and other physicians), P4P may present several troubling ethical issues. Because the current scope of P4P is limited to a few diseases, widespread implementation might lead to relative neglect of patients with other illnesses. Higher-risk patients might be avoided, and individual patient concerns might become subjugated to population performance measures. Hospitalists could face the additional conflict of being accountable to (and/or dependent upon) hospitals, which feel P4P pressures of their own. A final issue is the question of whether shared decision-making and patient-centered care mandate disclosure of non-public quality data to patients.

The American Medical Association (AMA) has a policy that specifically addresses P4P.2 Its “Pay-for-Performance Principles and Guidelines” call for physician participation in P4P to be voluntary and to allow physicians to access their ratings for potential appeal prior to wider release. The policy insists that quality of care be paramount over cost savings and that the physician-patient relationship be preserved. Of course, P4P programs may not share the AMA’s ethical concerns and are not bound to consider them.

Of particular concern—for both inpatient and outpatient physicians—is the fate of high-risk and unassigned patients. According to SHM’s 2005-2006 “Bi-Annual Survey on the State of the Hospital Medicine Movement” (www.hospital medicine.org), 96% of hospitalists are involved in the care of unassigned patients, and, in general, one of the strengths of hospital-based physicians should be their relative familiarity with the acute problems of patients who are older and of those with concomitant morbidities. Yet these are precisely the patient groups that are not well served by typical P4P measurements.

The potential for P4P incentives to create disparities in patient care among different patient groups and diseases is one of the prime concerns in the Council on Ethical and Judicial Affairs’ recent opinion for the AMA on P4P programs.3 The care of older patients, for instance, because of their own choices and due to frequency of comorbidities, may well come up short in performance measures designed for individuals who have a single disease.

This is not just a policy problem because P4P is not only unlikely to adequately address the ethical concerns of equitable care to these groups, it could exacerbate the vulnerability of these populations by creating a disincentive to provide care.4 A recent publication describing reports of cardiac surgeons turning away high-risk patients after “CABG report cards” became publicly available suggests that when given the option at least some physicians may indeed change their behavior when quality information is being collected and reported.5 Ironically, a system that incentivizes doctors to avoid the highest-risk patients could worsen—rather than improve—the overall quality of care.

Hospitalists may not be as sensitive to these pressures as surgeons or outpatient physicians, especially given the hospitalist’s limited flexibility in “choosing” patients. Care of unassigned patients may be a contractual obligation for which a hospitalist is paid by the hospital (which may face its own pressures in this area). And lower-risk referrals from outpatient physicians may “compensate” for the occasional complex patient.

Hospitalists are generally “need-based” practitioners who legally and ethically may not have the option to refuse care without risking patient abandonment. Yet the fact that hospitalists take on such patients may make their performance scores inferior to even non-hospital-based doctors—a difficult position to be in if one’s group receives payments from the hospital with an expectation of superior performance. Hospitalists in particular must consider whether or not insurance companies and the Centers for Medicare and Medicaid Services (CMS) could really accommodate all possible confounders in a risk-adjustment model to offset the nature of their patients. While the ethical choice might be for hospitalists simply to refuse to participate in P4P, citing multiple conflicts of interest, there is no clear indication regarding how “optional” these programs will be as they become increasingly prevalent, presenting yet another ethical issue.

Further, Medicare’s current P4P system for hospitals is directed at just five conditions, only two of which (congestive heart failure and pneumonia) are likely to fall within a hospitalist’s realm. But the list of common diagnoses under the hospitalist’s umbrella is, of course, much larger, including thromboembolism, pyelonephritis, COPD, cirrhosis, and sepsis. The data that exists for compliance with recommended care for some of these conditions (e.g., COPD) suggests that there may be substantial variability.6

But if hospitals base their support for hospitalist programs on their performance within a few CMS diagnoses, the effect on care for and development of appropriate guidelines and resources toward many other conditions may suffer. Already, hospital discharge forms are pre-printed with checkboxes for an angiotensin-converting enzyme (ACE) inhibitor prescription for congestive heart failure and counseling for smoking cessation. The (unethical) implication is that some diagnoses are more valuable than others, and that physician energies may be inequitably distributed—whether consciously or not. It is difficult to see how P4P could encompass standards for every patient condition, or how hospitals and providers could avoid focusing resources on those conditions that are more closely scrutinized by their payers.

Another issue arises if patient autonomy dictates that a treatment plan has to deviate from established guidelines; in such a case, hospitalists and other physicians may be forced to provide a care plan that is entirely reasonable from a medical standpoint but counts against them when compared with a benchmark. Ethical principles dictate that patient care be given priority, but unless consideration is made within the scoring system, performance measures that do not accommodate the ethical mandates to respect patient wishes or physician judgment are substantial pitfalls in the pursuit of better quality.7,8

One last issue concerns the question of whether or not providers have an obligation to disclose quality data to patients in the context of shared decision-making. This is a murky subject that involves determining the boundaries between the best means of pursuing quality improvement and the ethics of patient advocacy. The AMA’s Code of Medical Ethics states, “Patients should receive guidance from their physicians as to the optimal course of action,” and the issue of competence and responsibility to the care of the individual patient is the focus of several of the Principles of Medical Ethics. However, there is practically nothing published regarding the ethics, implications, or results of such disclosure, presumably because the availability of large amounts of quality-based data is such a new phenomenon and the considerations of such disclosure are so uncomfortable for many physicians.

Of course, some information—“CABG report cards,” for instance—is publicly available, but the evidence that patients actually utilize this information to a significant extent or that quality has improved due to its use is mixed.5 The question of whether an obligation exists to disclose non-public information when a provider knows that there is a question about performance relative to a benchmark or comparative peer group is uncharted water, ethically speaking; the issue is further complicated by the fact that appraisal of quality is far from a perfect science. It may be that the benefits of P4P result primarily from transparency, rather than from financial incentives. If so, disclosure may be the major component of quality reform, giving further weight to this question.

The ethical problems raised by P4P are underappreciated and inadequately discussed in the literature, particularly for how rapidly and rampantly these programs are being piloted and implemented. Although the AMA has taken a fairly clear and reasonable stance on the appropriate considerations for P4P programs, it is not clear that payers are incorporating all these concerns. A substantial number of hospitalist groups receive payments from medical groups or hospitals, which in turn are already involved in P4P for some diagnoses.

All hospitalists should read and familiarize themselves with these guidelines and carefully assess the implications of forthcoming P4P proposals for their own practices and patients. On a larger scale, SHM and its membership should strongly consider taking the lead in defining appropriate processes and outcomes for hospital care that incorporate these ethical concerns and allow for meaningful conclusions regarding both quality of care and opportunities for improvement.

Dr. Harte works at the Cleveland Clinic, and Dr. Rajput works at the Robert Wood Johnson Medical School, Camden, N.J. The authors wish to thank Tom Baudendistel and Donald Krause for their review and suggestions.

References

1. Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006 Mar 16;354:1147-1156.
2. American Medical Association. Pay-for-performance principles and guidelines. Accessible at: www.ama-assn.org/meetings/public/annual05/bot5a05.doc. Last accessed September 13, 2006.
3. American Medical Association. CEJA 3-1-05 Report, July 2006. Available at: www.ama-assn.org/ama/pub/category/4325.html. Last accessed September 13, 2006.
4. Morreim EH. Result-based compensation in health care: a good, but limited, idea. J Law Med Ethics. 2001 Summer;29(2):174-181.
5. Werner RM, Asch DA. The unintended consequences of publicly reporting quality information. JAMA. 2005 Mar 9;293:1239-1244.
6. Lindenauer PK, Pekow P, Gao S, et al. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 2006;144(12):894-903.
7. Walter LC, Davidowitz NP, Heineken PA, et al. Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure. JAMA. 2004 May 26;291(20):2466-2470.
8. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005 Aug 10;294(6):716-724.

In the not-too-distant future, a multiphysician hospitalist group is a participant in a pay-for-performance (P4P) program. Dr. Buchmann, the group’s lead hospitalist, is confronted by his hospital’s administration and informed that his doctors are performing below regional benchmarks for standards of care for community-acquired pneumonia, and, in fact, the hospital as a whole is below the mean performance levels.

The hospital threatens to break its contract with Dr. Buchmann’s group despite his response that his group sees a far more complex population than these standards can account for—and besides, his group has implemented a number of important quality initiatives in other diseases that are not part of the P4P program.

Several of the group’s hospitalists state that they will stop seeing indigent patients and will no longer take referrals for high-risk patients. Another partner feels it is unethical to continue treating pneumonia patients at the hospital without informing them of these quality findings and at least offering the option of transfer to a facility with better scores. Dr. Buchmann finds all these propositions unsettling.

While these physicians’ responses may sound extreme, the behavior of physicians caught between the hammer of financial survival and the anvil of professional ethics is unpredictable. Medicare and other payers have been implementing P4P plans as the latest attempt to stimulate quality reform. There are dozens of P4P-based programs operating in the United States, and the financial implications are daunting. Further, P4P is taking hold despite a relative paucity of research regarding its effectiveness in improving outcomes.

The underlying rationale of P4P is the use of economic incentives to stimulate changes in provider behavior. Recent work from the RAND Corporation suggests that as much as one-half of healthcare is not based on “accepted” best practices.1 And with increasing attention on the role of errors in medical practice, any effort to improve care seems, on its surface, laudable.

In general, key elements of P4P programs include a set of performance measures, the collection of data, comparison of provider data with benchmarks, and rewards for physicians who meet or exceed those targets. The interface between economic and financial incentives requires physicians to ensure that their behavior is in line with ethical and professional standards. While journals of medicine, law, and business contain many articles devoted to the policy and market implications of P4P, there is surprisingly little discussion in the literature regarding the potential ethical challenges that physicians may face in these programs.

For hospitalists (and other physicians), P4P may present several troubling ethical issues. Because the current scope of P4P is limited to a few diseases, widespread implementation might lead to relative neglect of patients with other illnesses. Higher-risk patients might be avoided, and individual patient concerns might become subjugated to population performance measures. Hospitalists could face the additional conflict of being accountable to (and/or dependent upon) hospitals, which feel P4P pressures of their own. A final issue is the question of whether shared decision-making and patient-centered care mandate disclosure of non-public quality data to patients.

The American Medical Association (AMA) has a policy that specifically addresses P4P.2 Its “Pay-for-Performance Principles and Guidelines” call for physician participation in P4P to be voluntary and to allow physicians to access their ratings for potential appeal prior to wider release. The policy insists that quality of care be paramount over cost savings and that the physician-patient relationship be preserved. Of course, P4P programs may not share the AMA’s ethical concerns and are not bound to consider them.

Of particular concern—for both inpatient and outpatient physicians—is the fate of high-risk and unassigned patients. According to SHM’s 2005-2006 “Bi-Annual Survey on the State of the Hospital Medicine Movement” (www.hospital medicine.org), 96% of hospitalists are involved in the care of unassigned patients, and, in general, one of the strengths of hospital-based physicians should be their relative familiarity with the acute problems of patients who are older and of those with concomitant morbidities. Yet these are precisely the patient groups that are not well served by typical P4P measurements.

The potential for P4P incentives to create disparities in patient care among different patient groups and diseases is one of the prime concerns in the Council on Ethical and Judicial Affairs’ recent opinion for the AMA on P4P programs.3 The care of older patients, for instance, because of their own choices and due to frequency of comorbidities, may well come up short in performance measures designed for individuals who have a single disease.

This is not just a policy problem because P4P is not only unlikely to adequately address the ethical concerns of equitable care to these groups, it could exacerbate the vulnerability of these populations by creating a disincentive to provide care.4 A recent publication describing reports of cardiac surgeons turning away high-risk patients after “CABG report cards” became publicly available suggests that when given the option at least some physicians may indeed change their behavior when quality information is being collected and reported.5 Ironically, a system that incentivizes doctors to avoid the highest-risk patients could worsen—rather than improve—the overall quality of care.

Hospitalists may not be as sensitive to these pressures as surgeons or outpatient physicians, especially given the hospitalist’s limited flexibility in “choosing” patients. Care of unassigned patients may be a contractual obligation for which a hospitalist is paid by the hospital (which may face its own pressures in this area). And lower-risk referrals from outpatient physicians may “compensate” for the occasional complex patient.

Hospitalists are generally “need-based” practitioners who legally and ethically may not have the option to refuse care without risking patient abandonment. Yet the fact that hospitalists take on such patients may make their performance scores inferior to even non-hospital-based doctors—a difficult position to be in if one’s group receives payments from the hospital with an expectation of superior performance. Hospitalists in particular must consider whether or not insurance companies and the Centers for Medicare and Medicaid Services (CMS) could really accommodate all possible confounders in a risk-adjustment model to offset the nature of their patients. While the ethical choice might be for hospitalists simply to refuse to participate in P4P, citing multiple conflicts of interest, there is no clear indication regarding how “optional” these programs will be as they become increasingly prevalent, presenting yet another ethical issue.

Further, Medicare’s current P4P system for hospitals is directed at just five conditions, only two of which (congestive heart failure and pneumonia) are likely to fall within a hospitalist’s realm. But the list of common diagnoses under the hospitalist’s umbrella is, of course, much larger, including thromboembolism, pyelonephritis, COPD, cirrhosis, and sepsis. The data that exists for compliance with recommended care for some of these conditions (e.g., COPD) suggests that there may be substantial variability.6

But if hospitals base their support for hospitalist programs on their performance within a few CMS diagnoses, the effect on care for and development of appropriate guidelines and resources toward many other conditions may suffer. Already, hospital discharge forms are pre-printed with checkboxes for an angiotensin-converting enzyme (ACE) inhibitor prescription for congestive heart failure and counseling for smoking cessation. The (unethical) implication is that some diagnoses are more valuable than others, and that physician energies may be inequitably distributed—whether consciously or not. It is difficult to see how P4P could encompass standards for every patient condition, or how hospitals and providers could avoid focusing resources on those conditions that are more closely scrutinized by their payers.

Another issue arises if patient autonomy dictates that a treatment plan has to deviate from established guidelines; in such a case, hospitalists and other physicians may be forced to provide a care plan that is entirely reasonable from a medical standpoint but counts against them when compared with a benchmark. Ethical principles dictate that patient care be given priority, but unless consideration is made within the scoring system, performance measures that do not accommodate the ethical mandates to respect patient wishes or physician judgment are substantial pitfalls in the pursuit of better quality.7,8

One last issue concerns the question of whether or not providers have an obligation to disclose quality data to patients in the context of shared decision-making. This is a murky subject that involves determining the boundaries between the best means of pursuing quality improvement and the ethics of patient advocacy. The AMA’s Code of Medical Ethics states, “Patients should receive guidance from their physicians as to the optimal course of action,” and the issue of competence and responsibility to the care of the individual patient is the focus of several of the Principles of Medical Ethics. However, there is practically nothing published regarding the ethics, implications, or results of such disclosure, presumably because the availability of large amounts of quality-based data is such a new phenomenon and the considerations of such disclosure are so uncomfortable for many physicians.

Of course, some information—“CABG report cards,” for instance—is publicly available, but the evidence that patients actually utilize this information to a significant extent or that quality has improved due to its use is mixed.5 The question of whether an obligation exists to disclose non-public information when a provider knows that there is a question about performance relative to a benchmark or comparative peer group is uncharted water, ethically speaking; the issue is further complicated by the fact that appraisal of quality is far from a perfect science. It may be that the benefits of P4P result primarily from transparency, rather than from financial incentives. If so, disclosure may be the major component of quality reform, giving further weight to this question.

The ethical problems raised by P4P are underappreciated and inadequately discussed in the literature, particularly for how rapidly and rampantly these programs are being piloted and implemented. Although the AMA has taken a fairly clear and reasonable stance on the appropriate considerations for P4P programs, it is not clear that payers are incorporating all these concerns. A substantial number of hospitalist groups receive payments from medical groups or hospitals, which in turn are already involved in P4P for some diagnoses.

All hospitalists should read and familiarize themselves with these guidelines and carefully assess the implications of forthcoming P4P proposals for their own practices and patients. On a larger scale, SHM and its membership should strongly consider taking the lead in defining appropriate processes and outcomes for hospital care that incorporate these ethical concerns and allow for meaningful conclusions regarding both quality of care and opportunities for improvement.

Dr. Harte works at the Cleveland Clinic, and Dr. Rajput works at the Robert Wood Johnson Medical School, Camden, N.J. The authors wish to thank Tom Baudendistel and Donald Krause for their review and suggestions.

References

1. Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006 Mar 16;354:1147-1156.
2. American Medical Association. Pay-for-performance principles and guidelines. Accessible at: www.ama-assn.org/meetings/public/annual05/bot5a05.doc. Last accessed September 13, 2006.
3. American Medical Association. CEJA 3-1-05 Report, July 2006. Available at: www.ama-assn.org/ama/pub/category/4325.html. Last accessed September 13, 2006.
4. Morreim EH. Result-based compensation in health care: a good, but limited, idea. J Law Med Ethics. 2001 Summer;29(2):174-181.
5. Werner RM, Asch DA. The unintended consequences of publicly reporting quality information. JAMA. 2005 Mar 9;293:1239-1244.
6. Lindenauer PK, Pekow P, Gao S, et al. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 2006;144(12):894-903.
7. Walter LC, Davidowitz NP, Heineken PA, et al. Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure. JAMA. 2004 May 26;291(20):2466-2470.
8. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005 Aug 10;294(6):716-724.

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

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

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

Rethinking Your Stereotype of the Uninsured

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

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

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

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

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

Implications for Hospitals and Hospitalists

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

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

Implications for Patients

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

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

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

Implications for Primary Care and the Health System

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

Implications for Business and America’s Future

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

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

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

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

Dr. Wellikson has been CEO of SHM since 2000.

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

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

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

Rethinking Your Stereotype of the Uninsured

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

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

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

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

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

Implications for Hospitals and Hospitalists

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

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

Implications for Patients

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

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

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

Implications for Primary Care and the Health System

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

Implications for Business and America’s Future

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

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

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

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

Dr. Wellikson has been CEO of SHM since 2000.

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

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

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

Rethinking Your Stereotype of the Uninsured

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

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

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

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

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

Implications for Hospitals and Hospitalists

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

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

Implications for Patients

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

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

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

Implications for Primary Care and the Health System

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

Implications for Business and America’s Future

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

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

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

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

Dr. Wellikson has been CEO of SHM since 2000.

The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”

Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.

Round and Round

Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.

One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.

Plugging into Patient Care

After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.

“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Afternoon: The Pace Picks up

After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.

At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.

Afternoon Consults

Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.

“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.

Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.

After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.

The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

System Challenges

Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.

In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”

Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.

Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”

Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.

The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.

With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.

Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”

Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”

Smooth the Way with Communication

Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.

“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”

Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”

He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.

What Keeps Him Going?

“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”

Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.

“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”

Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”

He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.

Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.

“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”

Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.

Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”

The Day Is Done: Satisfaction

“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”

His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH

Joanne Kaldy is frequent contributor to The Hospitalist.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”

Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.

Round and Round

Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.

One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.

Plugging into Patient Care

After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.

“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Afternoon: The Pace Picks up

After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.

At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.

Afternoon Consults

Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.

“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.

Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.

After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.

The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

System Challenges

Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.

In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”

Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.

Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”

Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.

The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.

With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.

Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”

Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”

Smooth the Way with Communication

Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.

“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”

Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”

He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.

What Keeps Him Going?

“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”

Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.

“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”

Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”

He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.

Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.

“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”

Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.

Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”

The Day Is Done: Satisfaction

“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”

His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH

Joanne Kaldy is frequent contributor to The Hospitalist.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”

Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.

Round and Round

Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.

One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.

Plugging into Patient Care

After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.

“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

Afternoon: The Pace Picks up

After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.

At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.

Afternoon Consults

Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.

“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.

Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.

After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.

The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.

Leon Reinstein, MD, has worked as a hospitalist for more than 20 years—long before the term “hospitalist” was commonly used.

System Challenges

Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.

In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”

Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.

Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”

Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.

The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.

With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.

Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”

Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”

Smooth the Way with Communication

Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.

“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”

Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”

He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.

What Keeps Him Going?

“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”

Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.

“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”

Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”

He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.

Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.

“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”

Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.

Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”

The Day Is Done: Satisfaction

“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”

His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH

Joanne Kaldy is frequent contributor to The Hospitalist.