Opinion

I think it is really cool that this publication has a series of articles on “What Cardiologists [or infection disease specialists, nephrologists, etc.] Want Hospitalists to Know.” I’m always interested to see which clinical topics made the list and which I’m already reasonably familiar with versus know little about. I’ve added this series to my list of things that are always worth the time to read, along with the “What’s New” section in UpToDate, review articles in major journals, and the Cleveland Clinic Journal of Medicine.

Not long ago, I worked with a hospitalist group that had agreed to cardiologists’ request that new hospitalists round with a cardiologist for something like three days as part of their orientation. This seems like they’ve taken the idea of “What Cardiologists Want Hospitalists to Know” a lot further than I had ever considered. I’m sure it would have value on many levels, including positioning the new hospitalist to work more effectively with the cardiologists, but I’m not sure it’s worth the cost. And I’m really concerned it sends a signal that the relationship is one way—that is, the hospitalists need to understand what the cardiologists do and want from them and not the reverse. For many reasons, I think this should be a reciprocal relationship, and it seems reasonable that new cardiologists should orient by rounding with hospitalists.

Same goes for the “… Want Hospitalists to Know” series. I’d like to see articles enumerating what hospitalists want doctors in other fields to know either in this magazine or its counterpart in the other specialty. What follows is the first of these. It is my take on non-clinical topics hospitalists want hospital leaders to know, and I’ll leave it to others to write about clinical topics.

We Aren’t on ‘Vacation’ Every Other Week

If you always think of our days off as a vacation, as in, “Those hospitalists get 26 weeks of vacation a year,” you’re making a mistake. A significant portion of our weekdays off are just like your weekends; they’re days to take a breather.

And you’re likely forgetting how many weekends we work.

And maybe lots of nights also.

You probably work more hours annually, but having more days for a breather are one offset for our weekends and nights.

Insisting Hospitalists Work an Entire Shift (12 Hours) Doesn’t Make a Lot of Sense on Slow Days

Staying around after completing clinical work yields no value. Too often, the time is spent watching YouTube or similar activities. And it means the doctor will be much more frustrated, and more likely to lobby for overtime compensation, when needing to stay beyond the scheduled end of the shift on busy days.

Avoid measuring work effort in hours. And in many cases, it is best to avoid precise determinations of when a day shift ends. At most hospitals, you do need at least one daytime doctor to stay on duty until the next shift arrives, but it rarely makes sense to have all of the hospitalists stay.

Your hospitalists need to be professional enough not to dash out the door the minute they’ve put notes on every patient’s chart. Instead, rather than leaving at the first opportunity on slow days, they could do all of the discharge preparation (med rec, discharge summary, etc.) for patients likely ready for discharge the next day; this can help a lot to discharge patients early the next day. Or they could make “secondary” rounds focused on patient satisfaction, etc.

Obs Patients Usually Are No Less Complicated—or Labor-Intensive—to Care For

It’s best to think of observation as solely a payor classification and not a good indicator of risk, complexity, or work required. Unfortunately “observation” is often thought of as shorthand for simple, not sick, easy to manage, etc. While true for a small subset of observation patients, such as younger people with a single problem such as atypical chest pain, it isn’t true for older (Medicare) patients with multiple chronic illnesses, on multiple medications, and with complex social situations.

Shouldn’t We Measure Length of Stay for All Patients in Hours Rather Than Days?

Then we could better understand throughput issues such as whether afternoon discharges for inpatients are late discharges or really very early discharges that weren’t held until the next morning.

Even High-Performing Hospitalist Groups Are Likely to Have Patient Satisfaction Scores on the Lower End of Doctors at Your Hospital

Don’t decide that just because they have much lower scores than the orthopedists, cardiologists, obstetricians, and other specialties, it is the hospitalists who are falling furthest below their potential. It may be the cardiologists who have a long way to go to achieve great scores for their specialty.

This isn’t an excuse. Just about every hospitalist group can do better and should work to make it happen. And because in nearly every hospital more HCAHPS surveys are attributed to hospitalists than any other specialty by a wide margin, our scores have a huge impact on the overall hospital averages. But you should keep in mind that, for a variety of reasons, hospitalists everywhere have physician communication scores that are lower than many or most other specialties.

To my knowledge, there isn’t a data set that provides patient satisfaction scores by specialty. And scores seem to vary a lot by geographic region, e.g., they’re nearly always higher in the South than other parts of the country. So there isn’t a good way to control for all the variables and know you’re setting appropriate improvement goals for each specialty. But your hospitalists will appreciate it if you acknowledge it may be unreasonable to set the same goals across specialties.

We’d Love Your Help Getting Rid of Pagers

Secure text messaging between all caregivers seems to be the way to go, and we will look to the hospital to make an investment in technology to make it possible and train users to ensure that by making messaging easier the volume of messages (interruptions) doesn’t just skyrocket. We, the hospitalists at your hospital, are happy to help with all of this, from vendor selection to plans for implementation. Please ask! TH

I think it is really cool that this publication has a series of articles on “What Cardiologists [or infection disease specialists, nephrologists, etc.] Want Hospitalists to Know.” I’m always interested to see which clinical topics made the list and which I’m already reasonably familiar with versus know little about. I’ve added this series to my list of things that are always worth the time to read, along with the “What’s New” section in UpToDate, review articles in major journals, and the Cleveland Clinic Journal of Medicine.

Not long ago, I worked with a hospitalist group that had agreed to cardiologists’ request that new hospitalists round with a cardiologist for something like three days as part of their orientation. This seems like they’ve taken the idea of “What Cardiologists Want Hospitalists to Know” a lot further than I had ever considered. I’m sure it would have value on many levels, including positioning the new hospitalist to work more effectively with the cardiologists, but I’m not sure it’s worth the cost. And I’m really concerned it sends a signal that the relationship is one way—that is, the hospitalists need to understand what the cardiologists do and want from them and not the reverse. For many reasons, I think this should be a reciprocal relationship, and it seems reasonable that new cardiologists should orient by rounding with hospitalists.

Same goes for the “… Want Hospitalists to Know” series. I’d like to see articles enumerating what hospitalists want doctors in other fields to know either in this magazine or its counterpart in the other specialty. What follows is the first of these. It is my take on non-clinical topics hospitalists want hospital leaders to know, and I’ll leave it to others to write about clinical topics.

We Aren’t on ‘Vacation’ Every Other Week

If you always think of our days off as a vacation, as in, “Those hospitalists get 26 weeks of vacation a year,” you’re making a mistake. A significant portion of our weekdays off are just like your weekends; they’re days to take a breather.

And you’re likely forgetting how many weekends we work.

And maybe lots of nights also.

You probably work more hours annually, but having more days for a breather are one offset for our weekends and nights.

Insisting Hospitalists Work an Entire Shift (12 Hours) Doesn’t Make a Lot of Sense on Slow Days

Staying around after completing clinical work yields no value. Too often, the time is spent watching YouTube or similar activities. And it means the doctor will be much more frustrated, and more likely to lobby for overtime compensation, when needing to stay beyond the scheduled end of the shift on busy days.

Avoid measuring work effort in hours. And in many cases, it is best to avoid precise determinations of when a day shift ends. At most hospitals, you do need at least one daytime doctor to stay on duty until the next shift arrives, but it rarely makes sense to have all of the hospitalists stay.

Your hospitalists need to be professional enough not to dash out the door the minute they’ve put notes on every patient’s chart. Instead, rather than leaving at the first opportunity on slow days, they could do all of the discharge preparation (med rec, discharge summary, etc.) for patients likely ready for discharge the next day; this can help a lot to discharge patients early the next day. Or they could make “secondary” rounds focused on patient satisfaction, etc.

Obs Patients Usually Are No Less Complicated—or Labor-Intensive—to Care For

It’s best to think of observation as solely a payor classification and not a good indicator of risk, complexity, or work required. Unfortunately “observation” is often thought of as shorthand for simple, not sick, easy to manage, etc. While true for a small subset of observation patients, such as younger people with a single problem such as atypical chest pain, it isn’t true for older (Medicare) patients with multiple chronic illnesses, on multiple medications, and with complex social situations.

Shouldn’t We Measure Length of Stay for All Patients in Hours Rather Than Days?

Then we could better understand throughput issues such as whether afternoon discharges for inpatients are late discharges or really very early discharges that weren’t held until the next morning.

Even High-Performing Hospitalist Groups Are Likely to Have Patient Satisfaction Scores on the Lower End of Doctors at Your Hospital

Don’t decide that just because they have much lower scores than the orthopedists, cardiologists, obstetricians, and other specialties, it is the hospitalists who are falling furthest below their potential. It may be the cardiologists who have a long way to go to achieve great scores for their specialty.

This isn’t an excuse. Just about every hospitalist group can do better and should work to make it happen. And because in nearly every hospital more HCAHPS surveys are attributed to hospitalists than any other specialty by a wide margin, our scores have a huge impact on the overall hospital averages. But you should keep in mind that, for a variety of reasons, hospitalists everywhere have physician communication scores that are lower than many or most other specialties.

To my knowledge, there isn’t a data set that provides patient satisfaction scores by specialty. And scores seem to vary a lot by geographic region, e.g., they’re nearly always higher in the South than other parts of the country. So there isn’t a good way to control for all the variables and know you’re setting appropriate improvement goals for each specialty. But your hospitalists will appreciate it if you acknowledge it may be unreasonable to set the same goals across specialties.

We’d Love Your Help Getting Rid of Pagers

Secure text messaging between all caregivers seems to be the way to go, and we will look to the hospital to make an investment in technology to make it possible and train users to ensure that by making messaging easier the volume of messages (interruptions) doesn’t just skyrocket. We, the hospitalists at your hospital, are happy to help with all of this, from vendor selection to plans for implementation. Please ask! TH

I think it is really cool that this publication has a series of articles on “What Cardiologists [or infection disease specialists, nephrologists, etc.] Want Hospitalists to Know.” I’m always interested to see which clinical topics made the list and which I’m already reasonably familiar with versus know little about. I’ve added this series to my list of things that are always worth the time to read, along with the “What’s New” section in UpToDate, review articles in major journals, and the Cleveland Clinic Journal of Medicine.

Not long ago, I worked with a hospitalist group that had agreed to cardiologists’ request that new hospitalists round with a cardiologist for something like three days as part of their orientation. This seems like they’ve taken the idea of “What Cardiologists Want Hospitalists to Know” a lot further than I had ever considered. I’m sure it would have value on many levels, including positioning the new hospitalist to work more effectively with the cardiologists, but I’m not sure it’s worth the cost. And I’m really concerned it sends a signal that the relationship is one way—that is, the hospitalists need to understand what the cardiologists do and want from them and not the reverse. For many reasons, I think this should be a reciprocal relationship, and it seems reasonable that new cardiologists should orient by rounding with hospitalists.

Same goes for the “… Want Hospitalists to Know” series. I’d like to see articles enumerating what hospitalists want doctors in other fields to know either in this magazine or its counterpart in the other specialty. What follows is the first of these. It is my take on non-clinical topics hospitalists want hospital leaders to know, and I’ll leave it to others to write about clinical topics.

We Aren’t on ‘Vacation’ Every Other Week

If you always think of our days off as a vacation, as in, “Those hospitalists get 26 weeks of vacation a year,” you’re making a mistake. A significant portion of our weekdays off are just like your weekends; they’re days to take a breather.

And you’re likely forgetting how many weekends we work.

And maybe lots of nights also.

You probably work more hours annually, but having more days for a breather are one offset for our weekends and nights.

Insisting Hospitalists Work an Entire Shift (12 Hours) Doesn’t Make a Lot of Sense on Slow Days

Staying around after completing clinical work yields no value. Too often, the time is spent watching YouTube or similar activities. And it means the doctor will be much more frustrated, and more likely to lobby for overtime compensation, when needing to stay beyond the scheduled end of the shift on busy days.

Avoid measuring work effort in hours. And in many cases, it is best to avoid precise determinations of when a day shift ends. At most hospitals, you do need at least one daytime doctor to stay on duty until the next shift arrives, but it rarely makes sense to have all of the hospitalists stay.

Your hospitalists need to be professional enough not to dash out the door the minute they’ve put notes on every patient’s chart. Instead, rather than leaving at the first opportunity on slow days, they could do all of the discharge preparation (med rec, discharge summary, etc.) for patients likely ready for discharge the next day; this can help a lot to discharge patients early the next day. Or they could make “secondary” rounds focused on patient satisfaction, etc.

Obs Patients Usually Are No Less Complicated—or Labor-Intensive—to Care For

It’s best to think of observation as solely a payor classification and not a good indicator of risk, complexity, or work required. Unfortunately “observation” is often thought of as shorthand for simple, not sick, easy to manage, etc. While true for a small subset of observation patients, such as younger people with a single problem such as atypical chest pain, it isn’t true for older (Medicare) patients with multiple chronic illnesses, on multiple medications, and with complex social situations.

Shouldn’t We Measure Length of Stay for All Patients in Hours Rather Than Days?

Then we could better understand throughput issues such as whether afternoon discharges for inpatients are late discharges or really very early discharges that weren’t held until the next morning.

Even High-Performing Hospitalist Groups Are Likely to Have Patient Satisfaction Scores on the Lower End of Doctors at Your Hospital

Don’t decide that just because they have much lower scores than the orthopedists, cardiologists, obstetricians, and other specialties, it is the hospitalists who are falling furthest below their potential. It may be the cardiologists who have a long way to go to achieve great scores for their specialty.

This isn’t an excuse. Just about every hospitalist group can do better and should work to make it happen. And because in nearly every hospital more HCAHPS surveys are attributed to hospitalists than any other specialty by a wide margin, our scores have a huge impact on the overall hospital averages. But you should keep in mind that, for a variety of reasons, hospitalists everywhere have physician communication scores that are lower than many or most other specialties.

To my knowledge, there isn’t a data set that provides patient satisfaction scores by specialty. And scores seem to vary a lot by geographic region, e.g., they’re nearly always higher in the South than other parts of the country. So there isn’t a good way to control for all the variables and know you’re setting appropriate improvement goals for each specialty. But your hospitalists will appreciate it if you acknowledge it may be unreasonable to set the same goals across specialties.

We’d Love Your Help Getting Rid of Pagers

Secure text messaging between all caregivers seems to be the way to go, and we will look to the hospital to make an investment in technology to make it possible and train users to ensure that by making messaging easier the volume of messages (interruptions) doesn’t just skyrocket. We, the hospitalists at your hospital, are happy to help with all of this, from vendor selection to plans for implementation. Please ask! TH

If you are a hospitalist, you are an entrepreneur almost by definition. All hospitalists are continuously engaged in improving the hospital experience for our patients. For some of us, the inner entrepreneur may grow to a point where we seriously consider a part-time or full-time commitment to an entrepreneurial dream. Combining our years of immersion in hospital patient care with an inventive streak can be a potent recipe for an innovative product or service idea.

It may be that the burgeoning startup scene in healthcare has inspired your dream. From coast to coast, there are startup incubators such as Rock Health, Healthbox, Blueprint Health, StartUp Health, Health Wildcatters, The Iron Yard, and TechSpring. These outfits support entrepreneurs with mentorship, funding, workspace, and/or information, such as how to deal with HIPAA or the FDA. Most of us have had at least a passing fascination with Steve Jobs–type characters, individuals who changed the world through their vision and force of will or who just seemed to enjoy a freedom that those who work for “The Man” will never know.

A few years ago, I caught the entrepreneurial bug. Initially, I continued with my day job and worked nights and weekends on my side project. Eventually, I made the leap to work full-time at an early-stage healthcare company. Since then, I’ve spent a lot of time trying to improve my new practice as a full-time entrepreneur, working as hard as ever, trying to be an effective innovator. Every day seems to bring new lessons—some more hard-earned than others—and there’s a lifetime of them still ahead. I’d like to share some of the insights I have learned on this journey. By the way, I still make time for patient care since that remains a priority for me.

Patience Is a Virtue, but Persistence and Positivity Count Even More

As Henry David Thoreau wrote, “Go confidently in the direction of your dreams.” Don’t postpone action indefinitely just because there are obstacles. Stop making excuses, make a start, and build momentum every day. Commit.

Becoming an entrepreneur is a long-term effort fueled by dedication and optimism, but first you have to make a start. You can’t win if you don’t play.

Action and Learning Matter More than Ideation

Start with your idea and a rough plan, but above all, believe in yourself, especially your ability to problem-solve. Many of the qualities that have fueled our success as physicians—precision, thoughtfulness, error aversion, and compulsiveness—might be constraints in a startup environment. Startups are hostile places for perfectionists and those who require complete information before proceeding. Have a bias for action and become comfortable with ambiguity. Entrepreneurs turn little things into big things by making progress every day.

Perhaps contrary to what we learn as physicians, entrepreneurs understand progress is measured more by authentic learning than by getting particular results. Entrepreneurs must quickly learn how to fail. In fact, progress often resembles multiple experiments that allow you to fail (and learn) faster. For entrepreneurs, perfection truly is the enemy of the good.

Learn, make adjustments, and progress will follow.

Guidance Is More Valuable than Money

Commercializing an idea is a challenging proposition. First-timers need advice, support, and help. For advice, find a mentor who has successfully launched a startup. Most of the successful people I know have had the wisdom or good fortune to have a mentor to provide guidance.

Startup incubators can be another source of support. Nearly all large cities and many medium and small cities now have business incubators or accelerators. Attend an event and get involved. They will provide many of the tools you will need to get started.

There are lots of opportunities for innovation in healthcare. But commercializing an idea will be one of the most challenging things you’ll ever do. Surround yourself with people who have skills that complement yours. Physician entrepreneurs need to be part of a viable team.

Sell, Sell, Sell

In business, as in life, “we’re all in sales.” We sell our ideas, our work product, ourselves. Even as physicians we have to sell patients and colleagues on our thought processes to be successful. Successful entrepreneurs are comfortable selling and put their best foot forward when trying to recruit a resource or persuade a potential customer.

Conflicts of Interest

“There is no interest without conflict.” If you look hard enough, you’ll see that we all have conflicts of interest. The key is to recognize them and disclose them. Of course, there are certain conflicts that are deal breakers. They must be avoided. If you remain employed, most of them are spelled out in your employer’s conflict of interest and intellectual property policies.

HIPAA Is an Innovation Killer

If your idea involves technology or services that address protected health information, become a HIPAA savant as soon as possible. The good news is that if you can effectively navigate the HIPAA challenge, you will have an advantage over your competitors.

Pure ‘Tech’ Plays Are Difficult

If you want to try to build the next killer app for healthcare and hope it will go viral, good luck. Based on my experience, it is difficult to get market traction with a pure technology offering. The strategy with a higher likelihood of success is to provide services with a technology platform that supports those services. As a provider of a service, you can provide immediate value to the customer and become “sticky” as you build your business (and software).

Enjoy the Journey, No Matter What

At first, you will be propelled by irrational exuberance and a passion for the greatness of your idea. That’s not only a good thing, it’s a requirement. But becoming a successful entrepreneur is a heavy haul down a long road of hard work and execution. Enjoying the journey is crucial since, beyond that, there are no guarantees. But life is short, so maybe you also value a career with no regrets. Take a chance and enjoy the ride.

Being a physician entrepreneur is not for everyone. But for those who take the plunge, it can be one of the most fulfilling, exciting, and meaningful journeys one could imagine. TH

Author note: I’d like to thank Dr. Jason Stein and Joe Miller for their helpful comments on this column.

If you are a hospitalist, you are an entrepreneur almost by definition. All hospitalists are continuously engaged in improving the hospital experience for our patients. For some of us, the inner entrepreneur may grow to a point where we seriously consider a part-time or full-time commitment to an entrepreneurial dream. Combining our years of immersion in hospital patient care with an inventive streak can be a potent recipe for an innovative product or service idea.

It may be that the burgeoning startup scene in healthcare has inspired your dream. From coast to coast, there are startup incubators such as Rock Health, Healthbox, Blueprint Health, StartUp Health, Health Wildcatters, The Iron Yard, and TechSpring. These outfits support entrepreneurs with mentorship, funding, workspace, and/or information, such as how to deal with HIPAA or the FDA. Most of us have had at least a passing fascination with Steve Jobs–type characters, individuals who changed the world through their vision and force of will or who just seemed to enjoy a freedom that those who work for “The Man” will never know.

A few years ago, I caught the entrepreneurial bug. Initially, I continued with my day job and worked nights and weekends on my side project. Eventually, I made the leap to work full-time at an early-stage healthcare company. Since then, I’ve spent a lot of time trying to improve my new practice as a full-time entrepreneur, working as hard as ever, trying to be an effective innovator. Every day seems to bring new lessons—some more hard-earned than others—and there’s a lifetime of them still ahead. I’d like to share some of the insights I have learned on this journey. By the way, I still make time for patient care since that remains a priority for me.

Patience Is a Virtue, but Persistence and Positivity Count Even More

As Henry David Thoreau wrote, “Go confidently in the direction of your dreams.” Don’t postpone action indefinitely just because there are obstacles. Stop making excuses, make a start, and build momentum every day. Commit.

Becoming an entrepreneur is a long-term effort fueled by dedication and optimism, but first you have to make a start. You can’t win if you don’t play.

Action and Learning Matter More than Ideation

Start with your idea and a rough plan, but above all, believe in yourself, especially your ability to problem-solve. Many of the qualities that have fueled our success as physicians—precision, thoughtfulness, error aversion, and compulsiveness—might be constraints in a startup environment. Startups are hostile places for perfectionists and those who require complete information before proceeding. Have a bias for action and become comfortable with ambiguity. Entrepreneurs turn little things into big things by making progress every day.

Perhaps contrary to what we learn as physicians, entrepreneurs understand progress is measured more by authentic learning than by getting particular results. Entrepreneurs must quickly learn how to fail. In fact, progress often resembles multiple experiments that allow you to fail (and learn) faster. For entrepreneurs, perfection truly is the enemy of the good.

Learn, make adjustments, and progress will follow.

Guidance Is More Valuable than Money

Commercializing an idea is a challenging proposition. First-timers need advice, support, and help. For advice, find a mentor who has successfully launched a startup. Most of the successful people I know have had the wisdom or good fortune to have a mentor to provide guidance.

Startup incubators can be another source of support. Nearly all large cities and many medium and small cities now have business incubators or accelerators. Attend an event and get involved. They will provide many of the tools you will need to get started.

There are lots of opportunities for innovation in healthcare. But commercializing an idea will be one of the most challenging things you’ll ever do. Surround yourself with people who have skills that complement yours. Physician entrepreneurs need to be part of a viable team.

Sell, Sell, Sell

In business, as in life, “we’re all in sales.” We sell our ideas, our work product, ourselves. Even as physicians we have to sell patients and colleagues on our thought processes to be successful. Successful entrepreneurs are comfortable selling and put their best foot forward when trying to recruit a resource or persuade a potential customer.

Conflicts of Interest

“There is no interest without conflict.” If you look hard enough, you’ll see that we all have conflicts of interest. The key is to recognize them and disclose them. Of course, there are certain conflicts that are deal breakers. They must be avoided. If you remain employed, most of them are spelled out in your employer’s conflict of interest and intellectual property policies.

HIPAA Is an Innovation Killer

If your idea involves technology or services that address protected health information, become a HIPAA savant as soon as possible. The good news is that if you can effectively navigate the HIPAA challenge, you will have an advantage over your competitors.

Pure ‘Tech’ Plays Are Difficult

If you want to try to build the next killer app for healthcare and hope it will go viral, good luck. Based on my experience, it is difficult to get market traction with a pure technology offering. The strategy with a higher likelihood of success is to provide services with a technology platform that supports those services. As a provider of a service, you can provide immediate value to the customer and become “sticky” as you build your business (and software).

Enjoy the Journey, No Matter What

At first, you will be propelled by irrational exuberance and a passion for the greatness of your idea. That’s not only a good thing, it’s a requirement. But becoming a successful entrepreneur is a heavy haul down a long road of hard work and execution. Enjoying the journey is crucial since, beyond that, there are no guarantees. But life is short, so maybe you also value a career with no regrets. Take a chance and enjoy the ride.

Being a physician entrepreneur is not for everyone. But for those who take the plunge, it can be one of the most fulfilling, exciting, and meaningful journeys one could imagine. TH

Author note: I’d like to thank Dr. Jason Stein and Joe Miller for their helpful comments on this column.

If you are a hospitalist, you are an entrepreneur almost by definition. All hospitalists are continuously engaged in improving the hospital experience for our patients. For some of us, the inner entrepreneur may grow to a point where we seriously consider a part-time or full-time commitment to an entrepreneurial dream. Combining our years of immersion in hospital patient care with an inventive streak can be a potent recipe for an innovative product or service idea.

It may be that the burgeoning startup scene in healthcare has inspired your dream. From coast to coast, there are startup incubators such as Rock Health, Healthbox, Blueprint Health, StartUp Health, Health Wildcatters, The Iron Yard, and TechSpring. These outfits support entrepreneurs with mentorship, funding, workspace, and/or information, such as how to deal with HIPAA or the FDA. Most of us have had at least a passing fascination with Steve Jobs–type characters, individuals who changed the world through their vision and force of will or who just seemed to enjoy a freedom that those who work for “The Man” will never know.

A few years ago, I caught the entrepreneurial bug. Initially, I continued with my day job and worked nights and weekends on my side project. Eventually, I made the leap to work full-time at an early-stage healthcare company. Since then, I’ve spent a lot of time trying to improve my new practice as a full-time entrepreneur, working as hard as ever, trying to be an effective innovator. Every day seems to bring new lessons—some more hard-earned than others—and there’s a lifetime of them still ahead. I’d like to share some of the insights I have learned on this journey. By the way, I still make time for patient care since that remains a priority for me.

Patience Is a Virtue, but Persistence and Positivity Count Even More

As Henry David Thoreau wrote, “Go confidently in the direction of your dreams.” Don’t postpone action indefinitely just because there are obstacles. Stop making excuses, make a start, and build momentum every day. Commit.

Becoming an entrepreneur is a long-term effort fueled by dedication and optimism, but first you have to make a start. You can’t win if you don’t play.

Action and Learning Matter More than Ideation

Start with your idea and a rough plan, but above all, believe in yourself, especially your ability to problem-solve. Many of the qualities that have fueled our success as physicians—precision, thoughtfulness, error aversion, and compulsiveness—might be constraints in a startup environment. Startups are hostile places for perfectionists and those who require complete information before proceeding. Have a bias for action and become comfortable with ambiguity. Entrepreneurs turn little things into big things by making progress every day.

Perhaps contrary to what we learn as physicians, entrepreneurs understand progress is measured more by authentic learning than by getting particular results. Entrepreneurs must quickly learn how to fail. In fact, progress often resembles multiple experiments that allow you to fail (and learn) faster. For entrepreneurs, perfection truly is the enemy of the good.

Learn, make adjustments, and progress will follow.

Guidance Is More Valuable than Money

Commercializing an idea is a challenging proposition. First-timers need advice, support, and help. For advice, find a mentor who has successfully launched a startup. Most of the successful people I know have had the wisdom or good fortune to have a mentor to provide guidance.

Startup incubators can be another source of support. Nearly all large cities and many medium and small cities now have business incubators or accelerators. Attend an event and get involved. They will provide many of the tools you will need to get started.

There are lots of opportunities for innovation in healthcare. But commercializing an idea will be one of the most challenging things you’ll ever do. Surround yourself with people who have skills that complement yours. Physician entrepreneurs need to be part of a viable team.

Sell, Sell, Sell

In business, as in life, “we’re all in sales.” We sell our ideas, our work product, ourselves. Even as physicians we have to sell patients and colleagues on our thought processes to be successful. Successful entrepreneurs are comfortable selling and put their best foot forward when trying to recruit a resource or persuade a potential customer.

Conflicts of Interest

“There is no interest without conflict.” If you look hard enough, you’ll see that we all have conflicts of interest. The key is to recognize them and disclose them. Of course, there are certain conflicts that are deal breakers. They must be avoided. If you remain employed, most of them are spelled out in your employer’s conflict of interest and intellectual property policies.

HIPAA Is an Innovation Killer

If your idea involves technology or services that address protected health information, become a HIPAA savant as soon as possible. The good news is that if you can effectively navigate the HIPAA challenge, you will have an advantage over your competitors.

Pure ‘Tech’ Plays Are Difficult

If you want to try to build the next killer app for healthcare and hope it will go viral, good luck. Based on my experience, it is difficult to get market traction with a pure technology offering. The strategy with a higher likelihood of success is to provide services with a technology platform that supports those services. As a provider of a service, you can provide immediate value to the customer and become “sticky” as you build your business (and software).

Enjoy the Journey, No Matter What

At first, you will be propelled by irrational exuberance and a passion for the greatness of your idea. That’s not only a good thing, it’s a requirement. But becoming a successful entrepreneur is a heavy haul down a long road of hard work and execution. Enjoying the journey is crucial since, beyond that, there are no guarantees. But life is short, so maybe you also value a career with no regrets. Take a chance and enjoy the ride.

Being a physician entrepreneur is not for everyone. But for those who take the plunge, it can be one of the most fulfilling, exciting, and meaningful journeys one could imagine. TH

Author note: I’d like to thank Dr. Jason Stein and Joe Miller for their helpful comments on this column.

In the first two installments of my own list of attributes that are important underpinnings of successful hospitalist groups, I covered group culture and decision making, recruiting, the importance of a written policy and procedure manual and performance dashboard, and roles for advanced practice clinicians. I’ll continue numbering from last month and complete the list in this column.

7. Clear Reporting Relationships

Most hospitalists are employed by one entity, usually a hospital subcorporation or staffing company, yet in many respects they report to someone else, such as a hospital CMO. For many, this can feel like serving two masters.

As an example, a hospitalist is employed by St. Excellence Medical Group (SEMG), a subsidiary of St. Excellence Hospital. Yet the hospital CMO is the key person establishing hospitalist performance targets, mediating disagreements between hospitalists and cardiologists, etc. So the hospitalists and CMO might jointly make plans for changes in the hospitalist practice that have staffing or budgetary implications only to find that the SEMG president resists spending more on the hospitalist program. For some hospitalist groups, this problem of being stuck between two masters can be a real barrier to getting things done.

Because the employed physician group nearly always directs most of its attention to outpatient care, the hospitalists are sometimes an afterthought, sort of a like a neglected stepchild. And worse, I’ve worked with more than one organization in which the CMO and physician president of the employed physician group are engaged in a power struggle, with the hospitalist group (and other physician specialties) caught in the middle and suffering as a result.

I think the best way out of this dilemma is for the employed physician group to function as a management services organization, providing human resources (payroll, etc.) and revenue cycle functions to the hospitalist groups. But for nearly all other issues, such as policies and procedures, staffing, strategic planning, hiring and firing, etc., the lead hospitalist should report to the CMO.

8. Well-Organized Group Meetings

My experience is that nearly every hospitalist group has periodic meetings to discuss and make decisions on operational and clinical issues. But the effectiveness of the meetings varies a lot. In some cases, they’re little more than disorganized gripe sessions.

I think most groups should have monthly meetings scheduled for about an hour or a little longer. Attendance at most meetings should be the expectation; that means even those not working clinically that day should be expected to attend unless away on vacation or some other meaningful conflict. Simply not being on clinical service that day should not be a reason to miss the meeting. Attendance by phone periodically is usually fine, especially for those who would otherwise have a long drive to attend in person or have child care duties, etc.

An agenda should be circulated in advance of the meeting; minutes, afterward. The best minutes highlight any “to-do” items, including person responsible and target completion date. Tasks occurring over longer than a month should be tracked in the minutes of every meeting until resolved. All past meeting minutes should be readily accessible via a network computer drive for review by any member of the group at any time.

Although some of every meeting will typically need to be devoted to one-way communication from the group leader or others, ideally in every meeting meaningful time should be devoted to joint problem-solving by all in attendance to ensure all are engaged in the meetings and find them useful. Some one-way communication (e.g., regular reports of performance data) typically can be distributed via email and other means rather than devoting meeting time to review it.

9. Effective Compensation

The amount of compensation should be competitive with your market, but because compensation is typically seen as an entitlement, unusually high compensation amounts usually have little impact on performance. But the method of compensation can matter, that is, the portion of total dollars that are fixed, tied to production, or tied to performance.

I think it’s best if the compensation method is generally similar to the way Medicare and other payors reimburse physician services. As payors tie increasing portions of compensation to performance and bundled payments, it makes sense for these changes to be mirrored in hospitalist compensation formulas to the extent that is practical. As I’ve written in February 2014 and many other times, I think there will always be a role for a portion of compensation tied to individual productivity.

According to SHM’s 2014 State of Hospital Medicine report, 64% of hospitalist groups have some component of compensation tied to citizenship activities such as committee participation, grand rounds presentations, community talks, publications, etc. I described a citizenship bonus program in detail in my November 2011 column. And while I was once an advocate of it, I’m now ambivalent. My anecdotal experience with the group I’m part of and many others I’ve worked with makes me suspect that a bonus for good citizenship might just squash intrinsic motivation as described in Daniel Pink’s book Drive.

If you do tie some portion of compensation to citizenship, I strongly encourage not connecting it to basic expectations like meeting attendance or turning in billing data on time. These are standard parts of the job, and citizenship pay should be reserved for going beyond the basics.

10. Good Social Connections

The way things look to me, doctors across all specialties have historically enjoyed robust and rewarding social connections with one another. But with each passing year, the nature of the work, financial pressures, and even clinical vocabulary become more and more different; that is, our Venn diagrams overlap less and less.

I think doctors in different specialties are becoming less connected, and disagreements or new stresses can more easily divide us.

Although all hospitals and medical groups are working hard to implement operational and technical adjustments to keep up with changing clinical practice and reimbursement models, I see very few deliberately focused on maintaining or strengthening the social connections and feeling of occupational solidarity and shared mission across doctors and other providers (see my June 2010 column). Those that do so—to my way of thinking—will be uniquely positioned to weather the storm of rapid change much more effectively. TH

In the first two installments of my own list of attributes that are important underpinnings of successful hospitalist groups, I covered group culture and decision making, recruiting, the importance of a written policy and procedure manual and performance dashboard, and roles for advanced practice clinicians. I’ll continue numbering from last month and complete the list in this column.

7. Clear Reporting Relationships

Most hospitalists are employed by one entity, usually a hospital subcorporation or staffing company, yet in many respects they report to someone else, such as a hospital CMO. For many, this can feel like serving two masters.

As an example, a hospitalist is employed by St. Excellence Medical Group (SEMG), a subsidiary of St. Excellence Hospital. Yet the hospital CMO is the key person establishing hospitalist performance targets, mediating disagreements between hospitalists and cardiologists, etc. So the hospitalists and CMO might jointly make plans for changes in the hospitalist practice that have staffing or budgetary implications only to find that the SEMG president resists spending more on the hospitalist program. For some hospitalist groups, this problem of being stuck between two masters can be a real barrier to getting things done.

Because the employed physician group nearly always directs most of its attention to outpatient care, the hospitalists are sometimes an afterthought, sort of a like a neglected stepchild. And worse, I’ve worked with more than one organization in which the CMO and physician president of the employed physician group are engaged in a power struggle, with the hospitalist group (and other physician specialties) caught in the middle and suffering as a result.

I think the best way out of this dilemma is for the employed physician group to function as a management services organization, providing human resources (payroll, etc.) and revenue cycle functions to the hospitalist groups. But for nearly all other issues, such as policies and procedures, staffing, strategic planning, hiring and firing, etc., the lead hospitalist should report to the CMO.

8. Well-Organized Group Meetings

My experience is that nearly every hospitalist group has periodic meetings to discuss and make decisions on operational and clinical issues. But the effectiveness of the meetings varies a lot. In some cases, they’re little more than disorganized gripe sessions.

I think most groups should have monthly meetings scheduled for about an hour or a little longer. Attendance at most meetings should be the expectation; that means even those not working clinically that day should be expected to attend unless away on vacation or some other meaningful conflict. Simply not being on clinical service that day should not be a reason to miss the meeting. Attendance by phone periodically is usually fine, especially for those who would otherwise have a long drive to attend in person or have child care duties, etc.

An agenda should be circulated in advance of the meeting; minutes, afterward. The best minutes highlight any “to-do” items, including person responsible and target completion date. Tasks occurring over longer than a month should be tracked in the minutes of every meeting until resolved. All past meeting minutes should be readily accessible via a network computer drive for review by any member of the group at any time.

Although some of every meeting will typically need to be devoted to one-way communication from the group leader or others, ideally in every meeting meaningful time should be devoted to joint problem-solving by all in attendance to ensure all are engaged in the meetings and find them useful. Some one-way communication (e.g., regular reports of performance data) typically can be distributed via email and other means rather than devoting meeting time to review it.

9. Effective Compensation

The amount of compensation should be competitive with your market, but because compensation is typically seen as an entitlement, unusually high compensation amounts usually have little impact on performance. But the method of compensation can matter, that is, the portion of total dollars that are fixed, tied to production, or tied to performance.

I think it’s best if the compensation method is generally similar to the way Medicare and other payors reimburse physician services. As payors tie increasing portions of compensation to performance and bundled payments, it makes sense for these changes to be mirrored in hospitalist compensation formulas to the extent that is practical. As I’ve written in February 2014 and many other times, I think there will always be a role for a portion of compensation tied to individual productivity.

According to SHM’s 2014 State of Hospital Medicine report, 64% of hospitalist groups have some component of compensation tied to citizenship activities such as committee participation, grand rounds presentations, community talks, publications, etc. I described a citizenship bonus program in detail in my November 2011 column. And while I was once an advocate of it, I’m now ambivalent. My anecdotal experience with the group I’m part of and many others I’ve worked with makes me suspect that a bonus for good citizenship might just squash intrinsic motivation as described in Daniel Pink’s book Drive.

If you do tie some portion of compensation to citizenship, I strongly encourage not connecting it to basic expectations like meeting attendance or turning in billing data on time. These are standard parts of the job, and citizenship pay should be reserved for going beyond the basics.

10. Good Social Connections

The way things look to me, doctors across all specialties have historically enjoyed robust and rewarding social connections with one another. But with each passing year, the nature of the work, financial pressures, and even clinical vocabulary become more and more different; that is, our Venn diagrams overlap less and less.

I think doctors in different specialties are becoming less connected, and disagreements or new stresses can more easily divide us.

Although all hospitals and medical groups are working hard to implement operational and technical adjustments to keep up with changing clinical practice and reimbursement models, I see very few deliberately focused on maintaining or strengthening the social connections and feeling of occupational solidarity and shared mission across doctors and other providers (see my June 2010 column). Those that do so—to my way of thinking—will be uniquely positioned to weather the storm of rapid change much more effectively. TH

In the first two installments of my own list of attributes that are important underpinnings of successful hospitalist groups, I covered group culture and decision making, recruiting, the importance of a written policy and procedure manual and performance dashboard, and roles for advanced practice clinicians. I’ll continue numbering from last month and complete the list in this column.

7. Clear Reporting Relationships

Most hospitalists are employed by one entity, usually a hospital subcorporation or staffing company, yet in many respects they report to someone else, such as a hospital CMO. For many, this can feel like serving two masters.

As an example, a hospitalist is employed by St. Excellence Medical Group (SEMG), a subsidiary of St. Excellence Hospital. Yet the hospital CMO is the key person establishing hospitalist performance targets, mediating disagreements between hospitalists and cardiologists, etc. So the hospitalists and CMO might jointly make plans for changes in the hospitalist practice that have staffing or budgetary implications only to find that the SEMG president resists spending more on the hospitalist program. For some hospitalist groups, this problem of being stuck between two masters can be a real barrier to getting things done.

Because the employed physician group nearly always directs most of its attention to outpatient care, the hospitalists are sometimes an afterthought, sort of a like a neglected stepchild. And worse, I’ve worked with more than one organization in which the CMO and physician president of the employed physician group are engaged in a power struggle, with the hospitalist group (and other physician specialties) caught in the middle and suffering as a result.

I think the best way out of this dilemma is for the employed physician group to function as a management services organization, providing human resources (payroll, etc.) and revenue cycle functions to the hospitalist groups. But for nearly all other issues, such as policies and procedures, staffing, strategic planning, hiring and firing, etc., the lead hospitalist should report to the CMO.

8. Well-Organized Group Meetings

My experience is that nearly every hospitalist group has periodic meetings to discuss and make decisions on operational and clinical issues. But the effectiveness of the meetings varies a lot. In some cases, they’re little more than disorganized gripe sessions.

I think most groups should have monthly meetings scheduled for about an hour or a little longer. Attendance at most meetings should be the expectation; that means even those not working clinically that day should be expected to attend unless away on vacation or some other meaningful conflict. Simply not being on clinical service that day should not be a reason to miss the meeting. Attendance by phone periodically is usually fine, especially for those who would otherwise have a long drive to attend in person or have child care duties, etc.

An agenda should be circulated in advance of the meeting; minutes, afterward. The best minutes highlight any “to-do” items, including person responsible and target completion date. Tasks occurring over longer than a month should be tracked in the minutes of every meeting until resolved. All past meeting minutes should be readily accessible via a network computer drive for review by any member of the group at any time.

Although some of every meeting will typically need to be devoted to one-way communication from the group leader or others, ideally in every meeting meaningful time should be devoted to joint problem-solving by all in attendance to ensure all are engaged in the meetings and find them useful. Some one-way communication (e.g., regular reports of performance data) typically can be distributed via email and other means rather than devoting meeting time to review it.

9. Effective Compensation

The amount of compensation should be competitive with your market, but because compensation is typically seen as an entitlement, unusually high compensation amounts usually have little impact on performance. But the method of compensation can matter, that is, the portion of total dollars that are fixed, tied to production, or tied to performance.

I think it’s best if the compensation method is generally similar to the way Medicare and other payors reimburse physician services. As payors tie increasing portions of compensation to performance and bundled payments, it makes sense for these changes to be mirrored in hospitalist compensation formulas to the extent that is practical. As I’ve written in February 2014 and many other times, I think there will always be a role for a portion of compensation tied to individual productivity.

According to SHM’s 2014 State of Hospital Medicine report, 64% of hospitalist groups have some component of compensation tied to citizenship activities such as committee participation, grand rounds presentations, community talks, publications, etc. I described a citizenship bonus program in detail in my November 2011 column. And while I was once an advocate of it, I’m now ambivalent. My anecdotal experience with the group I’m part of and many others I’ve worked with makes me suspect that a bonus for good citizenship might just squash intrinsic motivation as described in Daniel Pink’s book Drive.

If you do tie some portion of compensation to citizenship, I strongly encourage not connecting it to basic expectations like meeting attendance or turning in billing data on time. These are standard parts of the job, and citizenship pay should be reserved for going beyond the basics.

10. Good Social Connections

The way things look to me, doctors across all specialties have historically enjoyed robust and rewarding social connections with one another. But with each passing year, the nature of the work, financial pressures, and even clinical vocabulary become more and more different; that is, our Venn diagrams overlap less and less.

I think doctors in different specialties are becoming less connected, and disagreements or new stresses can more easily divide us.

Although all hospitals and medical groups are working hard to implement operational and technical adjustments to keep up with changing clinical practice and reimbursement models, I see very few deliberately focused on maintaining or strengthening the social connections and feeling of occupational solidarity and shared mission across doctors and other providers (see my June 2010 column). Those that do so—to my way of thinking—will be uniquely positioned to weather the storm of rapid change much more effectively. TH

In his insightful book “The Wisdom of Crowds” (New York: Anchor Books, 2004), James Surowiecke makes the convincing argument that many heads are wiser than one, even if that one is the sole expert regarding the subject under discussion. As long as the decision-making group is diverse, with each individual being allowed to come to an independent conclusion, this tenet appears to hold, whether the group is estimating the number of jelly beans in a jar or resolving a difficult issue. The message is clear: As a leader your leadership will be more effective if you solicit input from all members of your group, including those who may be reluctant to offer it.

In another excellent book, “Quiet” (New York: Crown Publishers, 2012), Susan Cain posits that, from early in the 20th century on, despite the considerable value it has to offer, introversion has become a “second-class personality trait.” Although highly valued earlier in our history, the thoughtful, introspective temperament was replaced by the aggressive, decisive character as the ideal.

Cain delves deeply into the substantial differences between extroverts and introverts, acknowledging that there are many gradations between the extremes. Extroverts tend to be loquacious and are seldom hesitant to offer their opinions on complex, difficult issues, even when their understanding of them is limited. They don’t always think before speaking and are less skilled listeners than introverts. They prefer to come to decisions rapidly, sometimes with incomplete data, and are much more decisive than introverts.

Introverts, on the other hand, prefer to listen rather than talk and to thoroughly vet an issue before reaching a decision. When they do, they are uncomfortable expressing it in a group setting. They prefer to work alone rather than in groups and, because of their thoughtful approach, their solutions to problems may be more innovative and sound than the shoot-from-the-hip, rapid answers that extroverts frequently propose. They abhor conflict and are likely to remain silent during controversy. In sum, although more difficult to elicit, obtaining input from the quiet members of the group is very worthwhile.

Often the most timely and ideal resolution is reached by balanced contributions from both personality types, the decision-making extroverts and the more thoughtful but reticent introverts. In fact, some of the best team members are those who are not on either extreme of the extrovert-introvert scale. But considering the fact that one-third to one-half of Americans are introverts (I suspect the fraction is a bit less among surgeons) and hesitant to offer their opinions in a group setting, how is this to be accomplished?

First, as a leader, you need to be sensitive to the fact that the introverts in your group are likely out of their comfort zone during communal meetings. It may even be embarrassing for them if they are called upon to offer their advice or opinion. To some degree this reluctance can be overcome by a leader who always attempts to reach consensus by valuing everyone’s opinion. Even the arrangement of the meeting room is important. The ideal is for all participants to be situated around a table rather than facing an imposing leader at the front of the room. This “leveling of the play field” emphasizes equality, de-emphasizes hierarchy, and encourages all to participate. The least likely to contribute can often be nudged from their quiet solitude by gentle urging from the leader with a statement such as: “Joe, I know you have a thoughtful perspective on this. Can you share it with the group?”

However, even the best-run meeting may not result in satisfactory resolution of difficult issues. In my experience, even those toward the extrovert end of the spectrum may be hesitant to offer their honest opinion in a meeting if it is in conflict with that of the leader. It is not uncommon to come to a consensus resolution of a controversial issue in a group meeting only to find out from hallway chatter that many disagree with the agreement reached. It is essential that the leader have access to this hallway chatter. This can be accomplished by way of confidantes who have the trust of both the troops and the leader.

During my years of leadership, a useful and productive technique I fostered to prompt input from introverts and honest assessments from all was to visit individual offices after the busy work day had quieted down, usually after 5 p.m. Meeting with individual faculty in their offices rather than in mine lent an informality to the conversation that could not be duplicated in the office of the chairman. In these one-on-one encounters, I found that even my relatively quiet faculty members felt comfortable in expressing their views regarding controversial issues facing our department. These informal chats also allowed me to become aware of problems they were facing in their professional and personal lives. They were great opportunities for mentoring and bonding as well. When these individual discussions precede what is anticipated to be a contentious group meeting, the likelihood of a successful conclusion is significantly enhanced.

Although my leadership experience was confined within the walls of academe, I believe these principles apply to anyone invited to lead a group in virtually any setting. Individual meetings are not an efficient way to lead, but they may provide a more effective and, in some cases, more rapid means of reaching consensus than innumerable group meetings with follow-up emails. When the group is too large to conference with everyone individually, one-on-one meetings with several key players may achieve the same result. During the process, don’t forget the quiet ones. They sometimes contribute the best and most innovative solutions to complex problems. There is power in quiet.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

In his insightful book “The Wisdom of Crowds” (New York: Anchor Books, 2004), James Surowiecke makes the convincing argument that many heads are wiser than one, even if that one is the sole expert regarding the subject under discussion. As long as the decision-making group is diverse, with each individual being allowed to come to an independent conclusion, this tenet appears to hold, whether the group is estimating the number of jelly beans in a jar or resolving a difficult issue. The message is clear: As a leader your leadership will be more effective if you solicit input from all members of your group, including those who may be reluctant to offer it.

In another excellent book, “Quiet” (New York: Crown Publishers, 2012), Susan Cain posits that, from early in the 20th century on, despite the considerable value it has to offer, introversion has become a “second-class personality trait.” Although highly valued earlier in our history, the thoughtful, introspective temperament was replaced by the aggressive, decisive character as the ideal.

Cain delves deeply into the substantial differences between extroverts and introverts, acknowledging that there are many gradations between the extremes. Extroverts tend to be loquacious and are seldom hesitant to offer their opinions on complex, difficult issues, even when their understanding of them is limited. They don’t always think before speaking and are less skilled listeners than introverts. They prefer to come to decisions rapidly, sometimes with incomplete data, and are much more decisive than introverts.

Introverts, on the other hand, prefer to listen rather than talk and to thoroughly vet an issue before reaching a decision. When they do, they are uncomfortable expressing it in a group setting. They prefer to work alone rather than in groups and, because of their thoughtful approach, their solutions to problems may be more innovative and sound than the shoot-from-the-hip, rapid answers that extroverts frequently propose. They abhor conflict and are likely to remain silent during controversy. In sum, although more difficult to elicit, obtaining input from the quiet members of the group is very worthwhile.

Often the most timely and ideal resolution is reached by balanced contributions from both personality types, the decision-making extroverts and the more thoughtful but reticent introverts. In fact, some of the best team members are those who are not on either extreme of the extrovert-introvert scale. But considering the fact that one-third to one-half of Americans are introverts (I suspect the fraction is a bit less among surgeons) and hesitant to offer their opinions in a group setting, how is this to be accomplished?

First, as a leader, you need to be sensitive to the fact that the introverts in your group are likely out of their comfort zone during communal meetings. It may even be embarrassing for them if they are called upon to offer their advice or opinion. To some degree this reluctance can be overcome by a leader who always attempts to reach consensus by valuing everyone’s opinion. Even the arrangement of the meeting room is important. The ideal is for all participants to be situated around a table rather than facing an imposing leader at the front of the room. This “leveling of the play field” emphasizes equality, de-emphasizes hierarchy, and encourages all to participate. The least likely to contribute can often be nudged from their quiet solitude by gentle urging from the leader with a statement such as: “Joe, I know you have a thoughtful perspective on this. Can you share it with the group?”

However, even the best-run meeting may not result in satisfactory resolution of difficult issues. In my experience, even those toward the extrovert end of the spectrum may be hesitant to offer their honest opinion in a meeting if it is in conflict with that of the leader. It is not uncommon to come to a consensus resolution of a controversial issue in a group meeting only to find out from hallway chatter that many disagree with the agreement reached. It is essential that the leader have access to this hallway chatter. This can be accomplished by way of confidantes who have the trust of both the troops and the leader.

During my years of leadership, a useful and productive technique I fostered to prompt input from introverts and honest assessments from all was to visit individual offices after the busy work day had quieted down, usually after 5 p.m. Meeting with individual faculty in their offices rather than in mine lent an informality to the conversation that could not be duplicated in the office of the chairman. In these one-on-one encounters, I found that even my relatively quiet faculty members felt comfortable in expressing their views regarding controversial issues facing our department. These informal chats also allowed me to become aware of problems they were facing in their professional and personal lives. They were great opportunities for mentoring and bonding as well. When these individual discussions precede what is anticipated to be a contentious group meeting, the likelihood of a successful conclusion is significantly enhanced.

Although my leadership experience was confined within the walls of academe, I believe these principles apply to anyone invited to lead a group in virtually any setting. Individual meetings are not an efficient way to lead, but they may provide a more effective and, in some cases, more rapid means of reaching consensus than innumerable group meetings with follow-up emails. When the group is too large to conference with everyone individually, one-on-one meetings with several key players may achieve the same result. During the process, don’t forget the quiet ones. They sometimes contribute the best and most innovative solutions to complex problems. There is power in quiet.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

In his insightful book “The Wisdom of Crowds” (New York: Anchor Books, 2004), James Surowiecke makes the convincing argument that many heads are wiser than one, even if that one is the sole expert regarding the subject under discussion. As long as the decision-making group is diverse, with each individual being allowed to come to an independent conclusion, this tenet appears to hold, whether the group is estimating the number of jelly beans in a jar or resolving a difficult issue. The message is clear: As a leader your leadership will be more effective if you solicit input from all members of your group, including those who may be reluctant to offer it.

In another excellent book, “Quiet” (New York: Crown Publishers, 2012), Susan Cain posits that, from early in the 20th century on, despite the considerable value it has to offer, introversion has become a “second-class personality trait.” Although highly valued earlier in our history, the thoughtful, introspective temperament was replaced by the aggressive, decisive character as the ideal.

Cain delves deeply into the substantial differences between extroverts and introverts, acknowledging that there are many gradations between the extremes. Extroverts tend to be loquacious and are seldom hesitant to offer their opinions on complex, difficult issues, even when their understanding of them is limited. They don’t always think before speaking and are less skilled listeners than introverts. They prefer to come to decisions rapidly, sometimes with incomplete data, and are much more decisive than introverts.

Introverts, on the other hand, prefer to listen rather than talk and to thoroughly vet an issue before reaching a decision. When they do, they are uncomfortable expressing it in a group setting. They prefer to work alone rather than in groups and, because of their thoughtful approach, their solutions to problems may be more innovative and sound than the shoot-from-the-hip, rapid answers that extroverts frequently propose. They abhor conflict and are likely to remain silent during controversy. In sum, although more difficult to elicit, obtaining input from the quiet members of the group is very worthwhile.

Often the most timely and ideal resolution is reached by balanced contributions from both personality types, the decision-making extroverts and the more thoughtful but reticent introverts. In fact, some of the best team members are those who are not on either extreme of the extrovert-introvert scale. But considering the fact that one-third to one-half of Americans are introverts (I suspect the fraction is a bit less among surgeons) and hesitant to offer their opinions in a group setting, how is this to be accomplished?

First, as a leader, you need to be sensitive to the fact that the introverts in your group are likely out of their comfort zone during communal meetings. It may even be embarrassing for them if they are called upon to offer their advice or opinion. To some degree this reluctance can be overcome by a leader who always attempts to reach consensus by valuing everyone’s opinion. Even the arrangement of the meeting room is important. The ideal is for all participants to be situated around a table rather than facing an imposing leader at the front of the room. This “leveling of the play field” emphasizes equality, de-emphasizes hierarchy, and encourages all to participate. The least likely to contribute can often be nudged from their quiet solitude by gentle urging from the leader with a statement such as: “Joe, I know you have a thoughtful perspective on this. Can you share it with the group?”

However, even the best-run meeting may not result in satisfactory resolution of difficult issues. In my experience, even those toward the extrovert end of the spectrum may be hesitant to offer their honest opinion in a meeting if it is in conflict with that of the leader. It is not uncommon to come to a consensus resolution of a controversial issue in a group meeting only to find out from hallway chatter that many disagree with the agreement reached. It is essential that the leader have access to this hallway chatter. This can be accomplished by way of confidantes who have the trust of both the troops and the leader.

During my years of leadership, a useful and productive technique I fostered to prompt input from introverts and honest assessments from all was to visit individual offices after the busy work day had quieted down, usually after 5 p.m. Meeting with individual faculty in their offices rather than in mine lent an informality to the conversation that could not be duplicated in the office of the chairman. In these one-on-one encounters, I found that even my relatively quiet faculty members felt comfortable in expressing their views regarding controversial issues facing our department. These informal chats also allowed me to become aware of problems they were facing in their professional and personal lives. They were great opportunities for mentoring and bonding as well. When these individual discussions precede what is anticipated to be a contentious group meeting, the likelihood of a successful conclusion is significantly enhanced.

Although my leadership experience was confined within the walls of academe, I believe these principles apply to anyone invited to lead a group in virtually any setting. Individual meetings are not an efficient way to lead, but they may provide a more effective and, in some cases, more rapid means of reaching consensus than innumerable group meetings with follow-up emails. When the group is too large to conference with everyone individually, one-on-one meetings with several key players may achieve the same result. During the process, don’t forget the quiet ones. They sometimes contribute the best and most innovative solutions to complex problems. There is power in quiet.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

Editor’s note: Second in a three-part series.

This month continues my list of important issues that help position your hospitalist group for greatest success. SHM’s “Key Principles and Characteristics of an Effective Hospital Medicine Group” is the definitive list, and this is my much smaller list. Last month, I discussed a culture (or mindset) of practice ownership, a formal system of group decision-making, and the importance of hospitalists themselves playing an active role in recruitment.

Policy and Procedure Manual

New protocols and decisions are being implemented every day. It is impossible to keep track of them, especially the ones that come into play infrequently. For example, many adult hospitalist groups have reached decisions about whether to admit teenagers (e.g., admit only 16 and older or 18 and older, etc.) and whether a hospitalist or obstetrician serves as attending for pregnant women admitted for a medical problem like asthma or pneumonia. But ask everyone in your group to recite the policies, and I bet the answers will differ.

My experience is that only about 20% to 25% of hospitalist groups have written these things down in one place, but all should. It doesn’t need to be fancy and could just start as a Word document in which the lead hospitalist or other designated person writes down a handful of policies and then updates them on an ongoing basis. For example, if a group meeting results in adopting a new policy, it could be added to the document as soon as the meeting adjourns. In some cases, a policy is communicated by email; it would be fine to just copy the body of that email into the manual.

This “living” document could be maintained on a shared computer drive accessible from anywhere in or out of the hospital. That way, when the solo night doctor thinks, “Do we admit 17-year-olds or not?,” she has a place to find the answer right away. And the manual will be a real asset to orient new providers to your practice.

You could start the policy and procedure manual by listing categories, including human resource issues like sick-day policy, how to request days off or scheduling changes, clinical policies like which hip fractures are admitted by hospitalists versus orthopedics, billing and coding practices such as always turn in charges at end of each day, and so on.

I’ve seen useful manuals that are about 10 pages and others that run more than 50 pages.

An Effective Performance Dashboard

Every hospitalist group should have some sort of routine performance report (dashboard) provided in the same format at regular intervals, yet in my experience many, or even most, don’t. It is worth the sometimes considerable effort to develop a meaningful dashboard, and in 2006, SHM published a helpful guide. Even though it is getting old, most of the advice is still very relevant even if the metrics we care most about have changed.

I’m a big believer in providing unblinded performance data to all in the hospitalist group. For example, a report of individual work relative value unit (wRVU) productivity would show productivity for each doctor by name. I think it is healthy to be transparent and ensure all in the group know how others are performing. There is nothing like finding out you are a performance outlier to spark an interest in understanding why and what should be done about it.

Roles for NPs and PAs

Nurse practitioners (NPs) and physician assistants (PAs) can be valuable contributors to a successful hospitalist program, and according to the 2014 State of Hospital Medicine Report, 65% of hospitalist groups nationally had at least one such clinician—an increase over prior years.

While the idea of NP/PAs contributing to the practice is a sound one, my experience is that many groups execute the idea poorly and end up creating a role that can be both professionally unsatisfying and not serve as a platform to contribute effectively to the group. A common scenario is a hospitalist group has trouble with recruiting physicians, so it turns to NP/PAs because they are more readily available. But so often the group has thought little about the precise role NP/PAs will serve (nothing more than “they will help out the docs”). Too often the result is NP/PAs who will say many physician hospitalists simply repeat all the work on each patient, which certainly isn’t a rewarding or cost-effective role.

All should be convinced that the practice is better off in terms of increased overall productivity and/or other benefits by investing in NP/PAs than if those same dollars were instead invested in physician staffing. So one economic model to consider is to calculate the total cost (salary, benefits, malpractice, etc.) for an NP/PA and divide that by those costs for a physician. Let’s say that shows an NP/PA costs half as much as a physician (ranges 40% to 60% in my experience). That staffing cost could be considered in “physician FTE equivalents” so that, for example, a practice with four NP/PAs each costing 50% as much as a physician, or two physician equivalents, could be said to have a total of two physician-equivalent FTEs of staffing. Is the practice better off configured that way, or would it be better to have two physicians instead of the four NP/PAs? The answer will vary, but I think every practice should look at NP/PA staffing through this lens, as well as other considerations, to determine whether they’ve made the best choice.

Having NP/PAs and physicians share rounding duties can be tricky to do efficiently. In my experience, NP/PAs can be better positioned to contribute optimally and find greater professional satisfaction if responsible for a specific portion of the group’s work. For example, at a large hospital, NP/PAs might see all orthopedic consults or psych unit admissions reasonably independently, though with physician backup available. Or NP/PAs could serve as evening (“swing”) shift staffing and manage cross-cover and some admissions. In these roles, the division of labor between NP/PAs and physicians is clearer and allows NP/PAs to contribute most effectively. TH

Editor’s note: Second in a three-part series.

This month continues my list of important issues that help position your hospitalist group for greatest success. SHM’s “Key Principles and Characteristics of an Effective Hospital Medicine Group” is the definitive list, and this is my much smaller list. Last month, I discussed a culture (or mindset) of practice ownership, a formal system of group decision-making, and the importance of hospitalists themselves playing an active role in recruitment.

Policy and Procedure Manual

New protocols and decisions are being implemented every day. It is impossible to keep track of them, especially the ones that come into play infrequently. For example, many adult hospitalist groups have reached decisions about whether to admit teenagers (e.g., admit only 16 and older or 18 and older, etc.) and whether a hospitalist or obstetrician serves as attending for pregnant women admitted for a medical problem like asthma or pneumonia. But ask everyone in your group to recite the policies, and I bet the answers will differ.

My experience is that only about 20% to 25% of hospitalist groups have written these things down in one place, but all should. It doesn’t need to be fancy and could just start as a Word document in which the lead hospitalist or other designated person writes down a handful of policies and then updates them on an ongoing basis. For example, if a group meeting results in adopting a new policy, it could be added to the document as soon as the meeting adjourns. In some cases, a policy is communicated by email; it would be fine to just copy the body of that email into the manual.

This “living” document could be maintained on a shared computer drive accessible from anywhere in or out of the hospital. That way, when the solo night doctor thinks, “Do we admit 17-year-olds or not?,” she has a place to find the answer right away. And the manual will be a real asset to orient new providers to your practice.

You could start the policy and procedure manual by listing categories, including human resource issues like sick-day policy, how to request days off or scheduling changes, clinical policies like which hip fractures are admitted by hospitalists versus orthopedics, billing and coding practices such as always turn in charges at end of each day, and so on.

I’ve seen useful manuals that are about 10 pages and others that run more than 50 pages.

An Effective Performance Dashboard

Every hospitalist group should have some sort of routine performance report (dashboard) provided in the same format at regular intervals, yet in my experience many, or even most, don’t. It is worth the sometimes considerable effort to develop a meaningful dashboard, and in 2006, SHM published a helpful guide. Even though it is getting old, most of the advice is still very relevant even if the metrics we care most about have changed.

I’m a big believer in providing unblinded performance data to all in the hospitalist group. For example, a report of individual work relative value unit (wRVU) productivity would show productivity for each doctor by name. I think it is healthy to be transparent and ensure all in the group know how others are performing. There is nothing like finding out you are a performance outlier to spark an interest in understanding why and what should be done about it.

Roles for NPs and PAs

Nurse practitioners (NPs) and physician assistants (PAs) can be valuable contributors to a successful hospitalist program, and according to the 2014 State of Hospital Medicine Report, 65% of hospitalist groups nationally had at least one such clinician—an increase over prior years.

While the idea of NP/PAs contributing to the practice is a sound one, my experience is that many groups execute the idea poorly and end up creating a role that can be both professionally unsatisfying and not serve as a platform to contribute effectively to the group. A common scenario is a hospitalist group has trouble with recruiting physicians, so it turns to NP/PAs because they are more readily available. But so often the group has thought little about the precise role NP/PAs will serve (nothing more than “they will help out the docs”). Too often the result is NP/PAs who will say many physician hospitalists simply repeat all the work on each patient, which certainly isn’t a rewarding or cost-effective role.

All should be convinced that the practice is better off in terms of increased overall productivity and/or other benefits by investing in NP/PAs than if those same dollars were instead invested in physician staffing. So one economic model to consider is to calculate the total cost (salary, benefits, malpractice, etc.) for an NP/PA and divide that by those costs for a physician. Let’s say that shows an NP/PA costs half as much as a physician (ranges 40% to 60% in my experience). That staffing cost could be considered in “physician FTE equivalents” so that, for example, a practice with four NP/PAs each costing 50% as much as a physician, or two physician equivalents, could be said to have a total of two physician-equivalent FTEs of staffing. Is the practice better off configured that way, or would it be better to have two physicians instead of the four NP/PAs? The answer will vary, but I think every practice should look at NP/PA staffing through this lens, as well as other considerations, to determine whether they’ve made the best choice.

Having NP/PAs and physicians share rounding duties can be tricky to do efficiently. In my experience, NP/PAs can be better positioned to contribute optimally and find greater professional satisfaction if responsible for a specific portion of the group’s work. For example, at a large hospital, NP/PAs might see all orthopedic consults or psych unit admissions reasonably independently, though with physician backup available. Or NP/PAs could serve as evening (“swing”) shift staffing and manage cross-cover and some admissions. In these roles, the division of labor between NP/PAs and physicians is clearer and allows NP/PAs to contribute most effectively. TH

Editor’s note: Second in a three-part series.

This month continues my list of important issues that help position your hospitalist group for greatest success. SHM’s “Key Principles and Characteristics of an Effective Hospital Medicine Group” is the definitive list, and this is my much smaller list. Last month, I discussed a culture (or mindset) of practice ownership, a formal system of group decision-making, and the importance of hospitalists themselves playing an active role in recruitment.

Policy and Procedure Manual

New protocols and decisions are being implemented every day. It is impossible to keep track of them, especially the ones that come into play infrequently. For example, many adult hospitalist groups have reached decisions about whether to admit teenagers (e.g., admit only 16 and older or 18 and older, etc.) and whether a hospitalist or obstetrician serves as attending for pregnant women admitted for a medical problem like asthma or pneumonia. But ask everyone in your group to recite the policies, and I bet the answers will differ.

My experience is that only about 20% to 25% of hospitalist groups have written these things down in one place, but all should. It doesn’t need to be fancy and could just start as a Word document in which the lead hospitalist or other designated person writes down a handful of policies and then updates them on an ongoing basis. For example, if a group meeting results in adopting a new policy, it could be added to the document as soon as the meeting adjourns. In some cases, a policy is communicated by email; it would be fine to just copy the body of that email into the manual.

This “living” document could be maintained on a shared computer drive accessible from anywhere in or out of the hospital. That way, when the solo night doctor thinks, “Do we admit 17-year-olds or not?,” she has a place to find the answer right away. And the manual will be a real asset to orient new providers to your practice.

You could start the policy and procedure manual by listing categories, including human resource issues like sick-day policy, how to request days off or scheduling changes, clinical policies like which hip fractures are admitted by hospitalists versus orthopedics, billing and coding practices such as always turn in charges at end of each day, and so on.

I’ve seen useful manuals that are about 10 pages and others that run more than 50 pages.

An Effective Performance Dashboard

Every hospitalist group should have some sort of routine performance report (dashboard) provided in the same format at regular intervals, yet in my experience many, or even most, don’t. It is worth the sometimes considerable effort to develop a meaningful dashboard, and in 2006, SHM published a helpful guide. Even though it is getting old, most of the advice is still very relevant even if the metrics we care most about have changed.

I’m a big believer in providing unblinded performance data to all in the hospitalist group. For example, a report of individual work relative value unit (wRVU) productivity would show productivity for each doctor by name. I think it is healthy to be transparent and ensure all in the group know how others are performing. There is nothing like finding out you are a performance outlier to spark an interest in understanding why and what should be done about it.

Roles for NPs and PAs

Nurse practitioners (NPs) and physician assistants (PAs) can be valuable contributors to a successful hospitalist program, and according to the 2014 State of Hospital Medicine Report, 65% of hospitalist groups nationally had at least one such clinician—an increase over prior years.

While the idea of NP/PAs contributing to the practice is a sound one, my experience is that many groups execute the idea poorly and end up creating a role that can be both professionally unsatisfying and not serve as a platform to contribute effectively to the group. A common scenario is a hospitalist group has trouble with recruiting physicians, so it turns to NP/PAs because they are more readily available. But so often the group has thought little about the precise role NP/PAs will serve (nothing more than “they will help out the docs”). Too often the result is NP/PAs who will say many physician hospitalists simply repeat all the work on each patient, which certainly isn’t a rewarding or cost-effective role.

All should be convinced that the practice is better off in terms of increased overall productivity and/or other benefits by investing in NP/PAs than if those same dollars were instead invested in physician staffing. So one economic model to consider is to calculate the total cost (salary, benefits, malpractice, etc.) for an NP/PA and divide that by those costs for a physician. Let’s say that shows an NP/PA costs half as much as a physician (ranges 40% to 60% in my experience). That staffing cost could be considered in “physician FTE equivalents” so that, for example, a practice with four NP/PAs each costing 50% as much as a physician, or two physician equivalents, could be said to have a total of two physician-equivalent FTEs of staffing. Is the practice better off configured that way, or would it be better to have two physicians instead of the four NP/PAs? The answer will vary, but I think every practice should look at NP/PA staffing through this lens, as well as other considerations, to determine whether they’ve made the best choice.

Having NP/PAs and physicians share rounding duties can be tricky to do efficiently. In my experience, NP/PAs can be better positioned to contribute optimally and find greater professional satisfaction if responsible for a specific portion of the group’s work. For example, at a large hospital, NP/PAs might see all orthopedic consults or psych unit admissions reasonably independently, though with physician backup available. Or NP/PAs could serve as evening (“swing”) shift staffing and manage cross-cover and some admissions. In these roles, the division of labor between NP/PAs and physicians is clearer and allows NP/PAs to contribute most effectively. TH

It has been two years since the “Key Characteristics” was published in the Journal of Hospital Medicine.1 The SHM board of directors envisions the Key Characteristics as a tool to improve the performance of hospital medicine groups (HMGs) and “raise the bar” for the specialty.

At SHM’s annual meeting (www.hospitalmedicine2016.org) next month in San Diego, the Key Characteristics will provide the framework for the Practice Management Pre-Course (Sunday, March 6). The pre-course faculty, of which I am a member, will address all 10 principles of the Key Characteristics (see Table 1), including case studies and practical ideas for performance improvement. As a preview, I will cover Principle 6 and provide a few practical tips that you can implement in your practice.

For a more comprehensive discussion of all the Key Characteristics and how to use them, visit the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page).

Characteristic 6.1

The HMG has systems in place to ensure effective and reliable communication with the patient’s primary care physician and/or other provider(s) involved in the patient’s care in the non-acute-care setting.

Practical tip: Your practice probably has administrative procedures in place to notify PCPs that their patient has been admitted to the hospital, using the electronic health record or secure email, if available, or messaging by fax/phone. But are you receiving vital information from the PCP’s office or from the nursing facility? Establish a protocol for obtaining key history, medication, and diagnostic testing information from these sources. One approach is to request this information when notifying the PCP of the patient’s admission.

Practical tip: Use the “grocery store test” to determine when to contact the PCP during the hospital stay. For example, if the PCP were to run into a family member of the patient in the grocery store, would the PCP want to have learned of a change in the patient’s condition in advance of the family member encounter?

Practical tip: Because reaching skilling nursing facility (SNF) physicians/providers (SNFists) can be challenging, hold an annual social event so that they can meet the hospitalists in your practice face-to-face. At the event, exchange cellphone or beeper numbers with the SNFists, and establish an explicit understanding of how handoffs will occur, especially for high-risk patients.

Characteristic 6.2

The HMG contributes in meaningful ways to the hospital’s efforts to improve care transitions.

Because of readmissions penalties, every hospital in the country is concerned with care transitions and avoiding readmissions. But HMGs want to know which interventions reliably decrease readmissions. The Commonwealth Fund recently released the results of a study of 428 hospitals that participated in national efforts to reduce readmissions, including the State Action on Avoidable Rehospitalizations (STAAR) and Hospital to Home (H2H) initiatives. The study’s primary conclusions were as follows:

• The only strategy consistently associated with reduced risk-standardized readmissions was discharging patients with their appointments already made.2 No other single strategy was reliably associated with a reduction.
• Hospitals that implemented three or more readmission reduction strategies showed a significant decrease in risk-standardized readmissions versus those implementing fewer than three.

Practical tip: Ensure patients leave the hospital with a PCP follow-up appointment made and in hand.

Practical tip: Work with your hospital on at least three definitive strategies to reduce readmissions.

Implement to Improve Your HMG

The basic and updated 2015 versions of the “Key Principles and Characteristics of an Effective Hospital Medicine Group” can be downloaded from the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page). The updated 2015 version provides definitions and requirements and suggested approaches to demonstrating the characteristic that enables the HMG to conduct a comprehensive self-assessment.

In addition, there is a new tool intended for use by hospitalist practice administrators that cross-references the Key Characteristics with another tool, The Core Competencies for a Hospitalist Practice Administrator. TH

References

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: an assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.
2. Bradley EH, Brewster A, Curry L. National campaigns to reduce readmissions: what have we learned? The Commonwealth Fund website. Available at: commonwealthfund.org/publications/blog/2015/oct/national-campaigns-to-reduce-readmissions. Accessed December 28, 2015.

It has been two years since the “Key Characteristics” was published in the Journal of Hospital Medicine.1 The SHM board of directors envisions the Key Characteristics as a tool to improve the performance of hospital medicine groups (HMGs) and “raise the bar” for the specialty.

At SHM’s annual meeting (www.hospitalmedicine2016.org) next month in San Diego, the Key Characteristics will provide the framework for the Practice Management Pre-Course (Sunday, March 6). The pre-course faculty, of which I am a member, will address all 10 principles of the Key Characteristics (see Table 1), including case studies and practical ideas for performance improvement. As a preview, I will cover Principle 6 and provide a few practical tips that you can implement in your practice.

For a more comprehensive discussion of all the Key Characteristics and how to use them, visit the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page).

Characteristic 6.1

The HMG has systems in place to ensure effective and reliable communication with the patient’s primary care physician and/or other provider(s) involved in the patient’s care in the non-acute-care setting.

Practical tip: Your practice probably has administrative procedures in place to notify PCPs that their patient has been admitted to the hospital, using the electronic health record or secure email, if available, or messaging by fax/phone. But are you receiving vital information from the PCP’s office or from the nursing facility? Establish a protocol for obtaining key history, medication, and diagnostic testing information from these sources. One approach is to request this information when notifying the PCP of the patient’s admission.

Practical tip: Use the “grocery store test” to determine when to contact the PCP during the hospital stay. For example, if the PCP were to run into a family member of the patient in the grocery store, would the PCP want to have learned of a change in the patient’s condition in advance of the family member encounter?

Practical tip: Because reaching skilling nursing facility (SNF) physicians/providers (SNFists) can be challenging, hold an annual social event so that they can meet the hospitalists in your practice face-to-face. At the event, exchange cellphone or beeper numbers with the SNFists, and establish an explicit understanding of how handoffs will occur, especially for high-risk patients.

Characteristic 6.2

The HMG contributes in meaningful ways to the hospital’s efforts to improve care transitions.

Because of readmissions penalties, every hospital in the country is concerned with care transitions and avoiding readmissions. But HMGs want to know which interventions reliably decrease readmissions. The Commonwealth Fund recently released the results of a study of 428 hospitals that participated in national efforts to reduce readmissions, including the State Action on Avoidable Rehospitalizations (STAAR) and Hospital to Home (H2H) initiatives. The study’s primary conclusions were as follows:

• The only strategy consistently associated with reduced risk-standardized readmissions was discharging patients with their appointments already made.2 No other single strategy was reliably associated with a reduction.
• Hospitals that implemented three or more readmission reduction strategies showed a significant decrease in risk-standardized readmissions versus those implementing fewer than three.

Practical tip: Ensure patients leave the hospital with a PCP follow-up appointment made and in hand.

Practical tip: Work with your hospital on at least three definitive strategies to reduce readmissions.

Implement to Improve Your HMG

The basic and updated 2015 versions of the “Key Principles and Characteristics of an Effective Hospital Medicine Group” can be downloaded from the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page). The updated 2015 version provides definitions and requirements and suggested approaches to demonstrating the characteristic that enables the HMG to conduct a comprehensive self-assessment.

In addition, there is a new tool intended for use by hospitalist practice administrators that cross-references the Key Characteristics with another tool, The Core Competencies for a Hospitalist Practice Administrator. TH

References

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: an assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.
2. Bradley EH, Brewster A, Curry L. National campaigns to reduce readmissions: what have we learned? The Commonwealth Fund website. Available at: commonwealthfund.org/publications/blog/2015/oct/national-campaigns-to-reduce-readmissions. Accessed December 28, 2015.

It has been two years since the “Key Characteristics” was published in the Journal of Hospital Medicine.1 The SHM board of directors envisions the Key Characteristics as a tool to improve the performance of hospital medicine groups (HMGs) and “raise the bar” for the specialty.

At SHM’s annual meeting (www.hospitalmedicine2016.org) next month in San Diego, the Key Characteristics will provide the framework for the Practice Management Pre-Course (Sunday, March 6). The pre-course faculty, of which I am a member, will address all 10 principles of the Key Characteristics (see Table 1), including case studies and practical ideas for performance improvement. As a preview, I will cover Principle 6 and provide a few practical tips that you can implement in your practice.

For a more comprehensive discussion of all the Key Characteristics and how to use them, visit the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page).

Characteristic 6.1

The HMG has systems in place to ensure effective and reliable communication with the patient’s primary care physician and/or other provider(s) involved in the patient’s care in the non-acute-care setting.

Practical tip: Your practice probably has administrative procedures in place to notify PCPs that their patient has been admitted to the hospital, using the electronic health record or secure email, if available, or messaging by fax/phone. But are you receiving vital information from the PCP’s office or from the nursing facility? Establish a protocol for obtaining key history, medication, and diagnostic testing information from these sources. One approach is to request this information when notifying the PCP of the patient’s admission.

Practical tip: Use the “grocery store test” to determine when to contact the PCP during the hospital stay. For example, if the PCP were to run into a family member of the patient in the grocery store, would the PCP want to have learned of a change in the patient’s condition in advance of the family member encounter?

Practical tip: Because reaching skilling nursing facility (SNF) physicians/providers (SNFists) can be challenging, hold an annual social event so that they can meet the hospitalists in your practice face-to-face. At the event, exchange cellphone or beeper numbers with the SNFists, and establish an explicit understanding of how handoffs will occur, especially for high-risk patients.

Characteristic 6.2

The HMG contributes in meaningful ways to the hospital’s efforts to improve care transitions.

Because of readmissions penalties, every hospital in the country is concerned with care transitions and avoiding readmissions. But HMGs want to know which interventions reliably decrease readmissions. The Commonwealth Fund recently released the results of a study of 428 hospitals that participated in national efforts to reduce readmissions, including the State Action on Avoidable Rehospitalizations (STAAR) and Hospital to Home (H2H) initiatives. The study’s primary conclusions were as follows:

• The only strategy consistently associated with reduced risk-standardized readmissions was discharging patients with their appointments already made.2 No other single strategy was reliably associated with a reduction.
• Hospitals that implemented three or more readmission reduction strategies showed a significant decrease in risk-standardized readmissions versus those implementing fewer than three.

Practical tip: Ensure patients leave the hospital with a PCP follow-up appointment made and in hand.

Practical tip: Work with your hospital on at least three definitive strategies to reduce readmissions.

Implement to Improve Your HMG

The basic and updated 2015 versions of the “Key Principles and Characteristics of an Effective Hospital Medicine Group” can be downloaded from the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page). The updated 2015 version provides definitions and requirements and suggested approaches to demonstrating the characteristic that enables the HMG to conduct a comprehensive self-assessment.

In addition, there is a new tool intended for use by hospitalist practice administrators that cross-references the Key Characteristics with another tool, The Core Competencies for a Hospitalist Practice Administrator. TH

References

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: an assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.
2. Bradley EH, Brewster A, Curry L. National campaigns to reduce readmissions: what have we learned? The Commonwealth Fund website. Available at: commonwealthfund.org/publications/blog/2015/oct/national-campaigns-to-reduce-readmissions. Accessed December 28, 2015.

Early in 2015, SHM published the updated edition of the “Key Principles and Characteristics of an Effective Hospital Medicine Group,” which is a free download via the SHM website. Every hospitalist group should use this comprehensive list of attributes as one important frame of reference to guide ongoing improvement efforts and long-range planning.

In this column and the next two, I’ll split the difference between the very brief list of top success factors for hospitalist groups I wrote about in my March 2011 column and the very comprehensive “Key Characteristics” document. I think these attributes are among the most important to support a high-performing group, yet they are sometimes overlooked or implemented poorly. They are of roughly equal importance and are listed in no particular order.

Deliberately Cultivating a Culture (or Mindset) of Practice Ownership

It’s easy for hospitalists to think of themselves as employees who just work shifts but have no need or opportunity to attend to the bigger picture of the practice or the hospital in which they operate. After all, being a good doctor for your patients is an awfully big job itself, and lots of recruitment ads tell you doctoring is all that will be expected of you. Someone else will handle everything necessary to ensure your practice is successful.

This line of thinking will limit the success of your group.

Your group will perform much better and you’re likely to find your career much more rewarding if you and your hospitalist colleagues think of yourselves as owning your practice and take an active role in managing it. You’ll still need others to manage day-to-day business affairs, but at least a portion of the hospitalists in the group should be actively involved in planning and making decisions about the group’s operations and future evolution.

I encounter hospitalist groups that have become convinced they don’t even have the opportunity to shape or influence their practice. “No one ever listens,” they say. “The hospital executives just do what they want regardless of what we say.” But in nearly every case, that is an exaggeration. Most administrative leaders desperately want hospitalist engagement and thoughtful participation in planning and decision making.

I wrote additional thoughts about the importance of a culture, or mindset, of practice ownership in August 2008. The print version of that column included a short list of questions you could ask yourself to assess whether your own group has such a culture, but it is missing from the web version and can be found at nelsonflores.com/html/quiz.html.

A Formal System of Group ‘Governance’

So many hospitalist groups rely almost entirely on consensus to make decisions. This might work well enough for a very small group (e.g., four or five doctors), but for large groups, it means just one or two dissenters can block a decision and nothing much gets done.

Disagreements about practice operations and future direction are common, so every group should commit to writing some method of how votes will be taken in the absence of consensus. For example, the group might be divided about whether to adopt unit-based assignments or change the hours of an evening (“swing”) shift, and a formal vote might be the only way to make a decision. It’s best if you have decided in advance issues such as what constitutes a quorum, who is eligible to vote, and whether the winning vote requires a simple or super-majority. And a formalized system of voting helps support a culture ownership.

I wrote about this originally in December 2007 and provided sample bylaws your group could modify as needed. Of course, you should keep in mind that if you are indeed employed by a larger entity such as a hospital or staffing company, you don’t have the ability to make all decisions by a vote of the group. Pay raises, staff additions, and similar decisions require support of the employer, and while a vote in support of them might influence what actually happens, it still requires the support of the employer. But there are lots of things, like the work schedule, system of allocating patients across providers, etc., that are usually best made by the group itself, and sometimes they might come down to a vote of the group.

Never Stop Recruiting and Ensure Hospitalists Themselves Are Actively Engaged in Recruiting

I wrote about recruiting originally in July 2008 when there was a shortage of hospitalists everywhere. Since then, the supply of doctors seeking work as a hospitalist has caught up with demand in many major metropolitan areas like Minneapolis and Washington, D.C.

But outside of large markets—that is, in most of the country—demand for hospitalists still far exceeds supply, and groups face ongoing staffing deficits that come with the need for existing doctors to work extra shifts and use locum tenens or other forms of temporary staffing. The potential excess supply of hospitalists in major markets may eventually trickle out and ease the shortages elsewhere, but that hasn’t happened in a big way yet. So for these places, it is crucial to devote a lot of energy and resources to recruiting.

A vital component of successful recruiting is participation in the effort by the hospitalists themselves. I think the best mindset for the hospitalists is to think of themselves as leading recruitment efforts assisted by recruiters rather than the other way around. For example, the lead hospitalist or some other designated doctor should try to respond by phone (if that’s impractical, then respond by email) to every reasonable inquiry from a new candidate within 24 hours and serve as the candidate’s principle point of communication throughout the recruitment process. The recruiter can handle details of things like arranging travel for an interview, but a hospitalist in the group should be the main source of information regarding things like the work schedule, patient volume, compensation, etc. And a hospitalist should serve as the main host during a candidate’s on-site interview.

More to Come …

Next month, I’ll address things like a written policy and procedure manual, clear reporting relationships for the hospitalist group, and roles for advanced practice clinicians (NPs and PAs). TH

Early in 2015, SHM published the updated edition of the “Key Principles and Characteristics of an Effective Hospital Medicine Group,” which is a free download via the SHM website. Every hospitalist group should use this comprehensive list of attributes as one important frame of reference to guide ongoing improvement efforts and long-range planning.

In this column and the next two, I’ll split the difference between the very brief list of top success factors for hospitalist groups I wrote about in my March 2011 column and the very comprehensive “Key Characteristics” document. I think these attributes are among the most important to support a high-performing group, yet they are sometimes overlooked or implemented poorly. They are of roughly equal importance and are listed in no particular order.

Deliberately Cultivating a Culture (or Mindset) of Practice Ownership

It’s easy for hospitalists to think of themselves as employees who just work shifts but have no need or opportunity to attend to the bigger picture of the practice or the hospital in which they operate. After all, being a good doctor for your patients is an awfully big job itself, and lots of recruitment ads tell you doctoring is all that will be expected of you. Someone else will handle everything necessary to ensure your practice is successful.

This line of thinking will limit the success of your group.

Your group will perform much better and you’re likely to find your career much more rewarding if you and your hospitalist colleagues think of yourselves as owning your practice and take an active role in managing it. You’ll still need others to manage day-to-day business affairs, but at least a portion of the hospitalists in the group should be actively involved in planning and making decisions about the group’s operations and future evolution.

I encounter hospitalist groups that have become convinced they don’t even have the opportunity to shape or influence their practice. “No one ever listens,” they say. “The hospital executives just do what they want regardless of what we say.” But in nearly every case, that is an exaggeration. Most administrative leaders desperately want hospitalist engagement and thoughtful participation in planning and decision making.

I wrote additional thoughts about the importance of a culture, or mindset, of practice ownership in August 2008. The print version of that column included a short list of questions you could ask yourself to assess whether your own group has such a culture, but it is missing from the web version and can be found at nelsonflores.com/html/quiz.html.

A Formal System of Group ‘Governance’

So many hospitalist groups rely almost entirely on consensus to make decisions. This might work well enough for a very small group (e.g., four or five doctors), but for large groups, it means just one or two dissenters can block a decision and nothing much gets done.

Disagreements about practice operations and future direction are common, so every group should commit to writing some method of how votes will be taken in the absence of consensus. For example, the group might be divided about whether to adopt unit-based assignments or change the hours of an evening (“swing”) shift, and a formal vote might be the only way to make a decision. It’s best if you have decided in advance issues such as what constitutes a quorum, who is eligible to vote, and whether the winning vote requires a simple or super-majority. And a formalized system of voting helps support a culture ownership.

I wrote about this originally in December 2007 and provided sample bylaws your group could modify as needed. Of course, you should keep in mind that if you are indeed employed by a larger entity such as a hospital or staffing company, you don’t have the ability to make all decisions by a vote of the group. Pay raises, staff additions, and similar decisions require support of the employer, and while a vote in support of them might influence what actually happens, it still requires the support of the employer. But there are lots of things, like the work schedule, system of allocating patients across providers, etc., that are usually best made by the group itself, and sometimes they might come down to a vote of the group.

Never Stop Recruiting and Ensure Hospitalists Themselves Are Actively Engaged in Recruiting

I wrote about recruiting originally in July 2008 when there was a shortage of hospitalists everywhere. Since then, the supply of doctors seeking work as a hospitalist has caught up with demand in many major metropolitan areas like Minneapolis and Washington, D.C.

But outside of large markets—that is, in most of the country—demand for hospitalists still far exceeds supply, and groups face ongoing staffing deficits that come with the need for existing doctors to work extra shifts and use locum tenens or other forms of temporary staffing. The potential excess supply of hospitalists in major markets may eventually trickle out and ease the shortages elsewhere, but that hasn’t happened in a big way yet. So for these places, it is crucial to devote a lot of energy and resources to recruiting.

A vital component of successful recruiting is participation in the effort by the hospitalists themselves. I think the best mindset for the hospitalists is to think of themselves as leading recruitment efforts assisted by recruiters rather than the other way around. For example, the lead hospitalist or some other designated doctor should try to respond by phone (if that’s impractical, then respond by email) to every reasonable inquiry from a new candidate within 24 hours and serve as the candidate’s principle point of communication throughout the recruitment process. The recruiter can handle details of things like arranging travel for an interview, but a hospitalist in the group should be the main source of information regarding things like the work schedule, patient volume, compensation, etc. And a hospitalist should serve as the main host during a candidate’s on-site interview.

More to Come …

Next month, I’ll address things like a written policy and procedure manual, clear reporting relationships for the hospitalist group, and roles for advanced practice clinicians (NPs and PAs). TH

Early in 2015, SHM published the updated edition of the “Key Principles and Characteristics of an Effective Hospital Medicine Group,” which is a free download via the SHM website. Every hospitalist group should use this comprehensive list of attributes as one important frame of reference to guide ongoing improvement efforts and long-range planning.

In this column and the next two, I’ll split the difference between the very brief list of top success factors for hospitalist groups I wrote about in my March 2011 column and the very comprehensive “Key Characteristics” document. I think these attributes are among the most important to support a high-performing group, yet they are sometimes overlooked or implemented poorly. They are of roughly equal importance and are listed in no particular order.

Deliberately Cultivating a Culture (or Mindset) of Practice Ownership

It’s easy for hospitalists to think of themselves as employees who just work shifts but have no need or opportunity to attend to the bigger picture of the practice or the hospital in which they operate. After all, being a good doctor for your patients is an awfully big job itself, and lots of recruitment ads tell you doctoring is all that will be expected of you. Someone else will handle everything necessary to ensure your practice is successful.

This line of thinking will limit the success of your group.

Your group will perform much better and you’re likely to find your career much more rewarding if you and your hospitalist colleagues think of yourselves as owning your practice and take an active role in managing it. You’ll still need others to manage day-to-day business affairs, but at least a portion of the hospitalists in the group should be actively involved in planning and making decisions about the group’s operations and future evolution.

I encounter hospitalist groups that have become convinced they don’t even have the opportunity to shape or influence their practice. “No one ever listens,” they say. “The hospital executives just do what they want regardless of what we say.” But in nearly every case, that is an exaggeration. Most administrative leaders desperately want hospitalist engagement and thoughtful participation in planning and decision making.

I wrote additional thoughts about the importance of a culture, or mindset, of practice ownership in August 2008. The print version of that column included a short list of questions you could ask yourself to assess whether your own group has such a culture, but it is missing from the web version and can be found at nelsonflores.com/html/quiz.html.

A Formal System of Group ‘Governance’

So many hospitalist groups rely almost entirely on consensus to make decisions. This might work well enough for a very small group (e.g., four or five doctors), but for large groups, it means just one or two dissenters can block a decision and nothing much gets done.

Disagreements about practice operations and future direction are common, so every group should commit to writing some method of how votes will be taken in the absence of consensus. For example, the group might be divided about whether to adopt unit-based assignments or change the hours of an evening (“swing”) shift, and a formal vote might be the only way to make a decision. It’s best if you have decided in advance issues such as what constitutes a quorum, who is eligible to vote, and whether the winning vote requires a simple or super-majority. And a formalized system of voting helps support a culture ownership.

I wrote about this originally in December 2007 and provided sample bylaws your group could modify as needed. Of course, you should keep in mind that if you are indeed employed by a larger entity such as a hospital or staffing company, you don’t have the ability to make all decisions by a vote of the group. Pay raises, staff additions, and similar decisions require support of the employer, and while a vote in support of them might influence what actually happens, it still requires the support of the employer. But there are lots of things, like the work schedule, system of allocating patients across providers, etc., that are usually best made by the group itself, and sometimes they might come down to a vote of the group.

Never Stop Recruiting and Ensure Hospitalists Themselves Are Actively Engaged in Recruiting

I wrote about recruiting originally in July 2008 when there was a shortage of hospitalists everywhere. Since then, the supply of doctors seeking work as a hospitalist has caught up with demand in many major metropolitan areas like Minneapolis and Washington, D.C.

But outside of large markets—that is, in most of the country—demand for hospitalists still far exceeds supply, and groups face ongoing staffing deficits that come with the need for existing doctors to work extra shifts and use locum tenens or other forms of temporary staffing. The potential excess supply of hospitalists in major markets may eventually trickle out and ease the shortages elsewhere, but that hasn’t happened in a big way yet. So for these places, it is crucial to devote a lot of energy and resources to recruiting.

A vital component of successful recruiting is participation in the effort by the hospitalists themselves. I think the best mindset for the hospitalists is to think of themselves as leading recruitment efforts assisted by recruiters rather than the other way around. For example, the lead hospitalist or some other designated doctor should try to respond by phone (if that’s impractical, then respond by email) to every reasonable inquiry from a new candidate within 24 hours and serve as the candidate’s principle point of communication throughout the recruitment process. The recruiter can handle details of things like arranging travel for an interview, but a hospitalist in the group should be the main source of information regarding things like the work schedule, patient volume, compensation, etc. And a hospitalist should serve as the main host during a candidate’s on-site interview.

More to Come …

Next month, I’ll address things like a written policy and procedure manual, clear reporting relationships for the hospitalist group, and roles for advanced practice clinicians (NPs and PAs). TH

We are into a new year, and among many New Year’s resolutions we hear is the resolution to take off body weight. That people are going for a new start, a chance to begin again, is actually good; it brings new hope and vigor to the issue. But sadly, most Americans making this resolution find themselves starting anew at a weight higher than they were the previous new year when they made the same resolution. Despite ourselves, we diet, exercise, and take off some pounds and then return to our previous behaviors that got us to wanting to take off the pounds in the first place.

Can psychiatry get into the body weight adventure and begin to lead the way to solutions? What I hope to do in this new column, “Weighty Issues,” is to share some of what I have learned in becoming an obesity medicine specialist, and learn from other experts who have been assessing and treating overweight and obesity for years.

I also hope to learn and share what we as psychiatrists are doing to manage our own weight (as many of us sit for a living) and lifestyles.

Coming to terms

About two-thirds of Americans are by medical calculations overweight, with half of that proportion actually medically obese. It is well-known that being overweight is a major risk factor for most of the illnesses that cause morbidity and early death among Americans. But this public health crisis was only classified an illness by the American Medical Association in 2013. What took us so long?

The topic of over body weight and psychiatry has been heavy on my mind for many years. It always puzzled me that psychiatry concentrated on anorexia nervosa, bulimia, and binge eating but was largely not focusing on the issue that was creeping up around us and becoming the major public health concern: that of overweight and obesity.

I knew that we were to concern ourselves only with illness but by ignoring the issue we, along with the rest of medicine, have promoted major, chronic illnesses of diabetes, heart disease, cancer, and so on. Fortunately for us, the AMA declared obesity a medical illness, but unfortunately, the way the reimbursement reads for treating obesity, one must be a sort of primary care physician or surgeon to get paid for the work. To my way of thinking, psychiatrists are the best physicians to be working in the field of overweight and obesity medicine, because we – more than any other medical specialty – understand that thoughts and feelings are involved in behavior. We understand that to be successful long-term in any endeavor, one must understand and harness one’s thoughts and feelings.

Moreover, we, more than physicians in other specialties, understand that the treater’s simple transference and countertransference, and the patient’s transference, can determine the trajectory and outcome of the treatment process. Additionally, psychiatrists regularly see their patients more often and over longer periods of time than do other physicians while developing and maintaining respectful and supportive relationships that can best handle the very personal issue of weight.

Surgery often not the answer

After having been a part of many psychiatric and psychological pre–bariatric surgery screenings over many years and having known many patients, friends, and colleagues who had undergone the different surgical treatments for overweight with complications and/or obesity, only to see them, many years later, larger than they were before the surgical intervention, I began to think that cutting it out was not the only definitive way to get better health measures. I knew that each surgical candidate really meant it when they pledged to follow through indefinitely but that feelings and life had intervened, and those were more powerful than surgery. That led me to think like a psychiatrist, and learn from and keep on learning from the feelings throughout life’s challenges and not like a surgeon, whose view is “once it is cut out, it is finished.”

It even led me to think medically radical thoughts that rapid weight loss through diet and lifestyle intervention, such as the weight loss that is achieved through surgery, could be a very good thing with one major caveat ... long-term intervention (psychiatry, the discipline, knows something about long-term intervention). That kind of thinking led me to try to register for a lifestyle program that was sold out at that time. A course in Obesity Medicine, the crux of the matter, was not sold out. I took one course and was hooked, learning all that I did not know about overweight and obesity, and realizing just how complicated the matter of weight actually is.

In time, I studied and learned more, saw more patients, and became a diplomate of the American Board of Obesity Medicine (ABOM). Of the approximately 1,300 diplomates of the ABOM, only 15 identify as having psychiatry as their primary specialty. The board reports that there may be other psychiatrists who are also boarded in internal medicine or pediatrics or surgery, but specific information is not available.

Those of us who prescribe typical and atypical antipsychotic agents and some of the older and newer antidepressants are familiar with the weight gain that can be attendant to these medications. We also are familiar with metabolic syndrome, which can be associated and our need to follow fasting blood glucose and lipid levels as well as waist circumference, height, and weight.

Many of us also will educate our patients about eating fewer sweets and drinking fewer sugar sweetened beverages, consuming fewer starches, and we will advise our patients to increase their exercise. We may even prescribe metformin if the fasting blood sugar and hemoglobin A1C begin to creep upward. In addition, we are constantly trying to offset the side effects of medications that we prescribe for very serious illnesses. In short, psychiatrists already are in the obesity medicine arena.

Addressing personal challenges

Talking the talk and walking the walk is so important in the area of overweight and obesity. I have struggled with overweight most of my adult life and have been “overnutritioned” – the Chinese term for overweight, off and on during my career in psychiatry. During my obesity medicine studies, I took my own weight and lifestyle seriously, and lost a significant amount of weight. Friends and patients asked me if I were well. Over time, some patients who had been with me for years volunteered how they felt about my voluntary weight loss. Most said that I no longer looked powerful; some said that I looked like a lightweight – not a serious person.

Interestingly, over time, all of my patients who had weight issues of their own began to manage their own weight better, and began to talk about their feelings and relationship to food, exercise, and weight. We have all realized that there is more under that puffy cover than meets the eye and that it insulates a whole host of stuff. Calories in and calories out become a superficial path toward a solution.

Regarding simple transference and countertransference ... many physicians have powerful adverse feelings about patients who are overweight or obese and really struggle with working with these patients. One of my friends, a family medicine specialist, told me that he cannot look at them and has told his staff not to assign those patients to him, because they do not comply and then do not come back to follow up. It is likely that his patients pick up on his disdain, anger, and lack of hope for them, and do not return in order to protect their feelings. Interestingly, this friend has struggled with his own weight throughout his professional life. Perhaps psychiatry could be useful to the myriad of other physicians like my friend who have visceral reactions to patients with weight issues so that the physicians can be kinder to themselves and their patients can receive the care, understanding, and respect that they deserve.

Attaining and maintaining a healthy weight across the life cycles is a complicated thought-, feeling-, and event-filled endeavor. I look forward to sharing basic science, clinical science, research, and anecdotal reports as we explore “Weighty Issues.”

Dr. Harris, a diplomate of the American Board of Obesity Medicine, is in private practice in adult and geriatric psychiatry in Hartford, Conn. She also works as a psychiatric consultant to continuing care retirement organizations and professional groups. Dr. Harris, a former president of the Black Psychiatrists of America, is a Distinguished Fellow of the American Psychiatric Association. Besides psychotherapy, her major clinical interests include geriatrics and the interface between general medicine and psychiatry.

We are into a new year, and among many New Year’s resolutions we hear is the resolution to take off body weight. That people are going for a new start, a chance to begin again, is actually good; it brings new hope and vigor to the issue. But sadly, most Americans making this resolution find themselves starting anew at a weight higher than they were the previous new year when they made the same resolution. Despite ourselves, we diet, exercise, and take off some pounds and then return to our previous behaviors that got us to wanting to take off the pounds in the first place.

Can psychiatry get into the body weight adventure and begin to lead the way to solutions? What I hope to do in this new column, “Weighty Issues,” is to share some of what I have learned in becoming an obesity medicine specialist, and learn from other experts who have been assessing and treating overweight and obesity for years.

I also hope to learn and share what we as psychiatrists are doing to manage our own weight (as many of us sit for a living) and lifestyles.

Coming to terms

About two-thirds of Americans are by medical calculations overweight, with half of that proportion actually medically obese. It is well-known that being overweight is a major risk factor for most of the illnesses that cause morbidity and early death among Americans. But this public health crisis was only classified an illness by the American Medical Association in 2013. What took us so long?

The topic of over body weight and psychiatry has been heavy on my mind for many years. It always puzzled me that psychiatry concentrated on anorexia nervosa, bulimia, and binge eating but was largely not focusing on the issue that was creeping up around us and becoming the major public health concern: that of overweight and obesity.

I knew that we were to concern ourselves only with illness but by ignoring the issue we, along with the rest of medicine, have promoted major, chronic illnesses of diabetes, heart disease, cancer, and so on. Fortunately for us, the AMA declared obesity a medical illness, but unfortunately, the way the reimbursement reads for treating obesity, one must be a sort of primary care physician or surgeon to get paid for the work. To my way of thinking, psychiatrists are the best physicians to be working in the field of overweight and obesity medicine, because we – more than any other medical specialty – understand that thoughts and feelings are involved in behavior. We understand that to be successful long-term in any endeavor, one must understand and harness one’s thoughts and feelings.

Moreover, we, more than physicians in other specialties, understand that the treater’s simple transference and countertransference, and the patient’s transference, can determine the trajectory and outcome of the treatment process. Additionally, psychiatrists regularly see their patients more often and over longer periods of time than do other physicians while developing and maintaining respectful and supportive relationships that can best handle the very personal issue of weight.

Surgery often not the answer

After having been a part of many psychiatric and psychological pre–bariatric surgery screenings over many years and having known many patients, friends, and colleagues who had undergone the different surgical treatments for overweight with complications and/or obesity, only to see them, many years later, larger than they were before the surgical intervention, I began to think that cutting it out was not the only definitive way to get better health measures. I knew that each surgical candidate really meant it when they pledged to follow through indefinitely but that feelings and life had intervened, and those were more powerful than surgery. That led me to think like a psychiatrist, and learn from and keep on learning from the feelings throughout life’s challenges and not like a surgeon, whose view is “once it is cut out, it is finished.”

It even led me to think medically radical thoughts that rapid weight loss through diet and lifestyle intervention, such as the weight loss that is achieved through surgery, could be a very good thing with one major caveat ... long-term intervention (psychiatry, the discipline, knows something about long-term intervention). That kind of thinking led me to try to register for a lifestyle program that was sold out at that time. A course in Obesity Medicine, the crux of the matter, was not sold out. I took one course and was hooked, learning all that I did not know about overweight and obesity, and realizing just how complicated the matter of weight actually is.

In time, I studied and learned more, saw more patients, and became a diplomate of the American Board of Obesity Medicine (ABOM). Of the approximately 1,300 diplomates of the ABOM, only 15 identify as having psychiatry as their primary specialty. The board reports that there may be other psychiatrists who are also boarded in internal medicine or pediatrics or surgery, but specific information is not available.

Those of us who prescribe typical and atypical antipsychotic agents and some of the older and newer antidepressants are familiar with the weight gain that can be attendant to these medications. We also are familiar with metabolic syndrome, which can be associated and our need to follow fasting blood glucose and lipid levels as well as waist circumference, height, and weight.

Many of us also will educate our patients about eating fewer sweets and drinking fewer sugar sweetened beverages, consuming fewer starches, and we will advise our patients to increase their exercise. We may even prescribe metformin if the fasting blood sugar and hemoglobin A1C begin to creep upward. In addition, we are constantly trying to offset the side effects of medications that we prescribe for very serious illnesses. In short, psychiatrists already are in the obesity medicine arena.

Addressing personal challenges

Talking the talk and walking the walk is so important in the area of overweight and obesity. I have struggled with overweight most of my adult life and have been “overnutritioned” – the Chinese term for overweight, off and on during my career in psychiatry. During my obesity medicine studies, I took my own weight and lifestyle seriously, and lost a significant amount of weight. Friends and patients asked me if I were well. Over time, some patients who had been with me for years volunteered how they felt about my voluntary weight loss. Most said that I no longer looked powerful; some said that I looked like a lightweight – not a serious person.

Interestingly, over time, all of my patients who had weight issues of their own began to manage their own weight better, and began to talk about their feelings and relationship to food, exercise, and weight. We have all realized that there is more under that puffy cover than meets the eye and that it insulates a whole host of stuff. Calories in and calories out become a superficial path toward a solution.

Regarding simple transference and countertransference ... many physicians have powerful adverse feelings about patients who are overweight or obese and really struggle with working with these patients. One of my friends, a family medicine specialist, told me that he cannot look at them and has told his staff not to assign those patients to him, because they do not comply and then do not come back to follow up. It is likely that his patients pick up on his disdain, anger, and lack of hope for them, and do not return in order to protect their feelings. Interestingly, this friend has struggled with his own weight throughout his professional life. Perhaps psychiatry could be useful to the myriad of other physicians like my friend who have visceral reactions to patients with weight issues so that the physicians can be kinder to themselves and their patients can receive the care, understanding, and respect that they deserve.

Attaining and maintaining a healthy weight across the life cycles is a complicated thought-, feeling-, and event-filled endeavor. I look forward to sharing basic science, clinical science, research, and anecdotal reports as we explore “Weighty Issues.”

Dr. Harris, a diplomate of the American Board of Obesity Medicine, is in private practice in adult and geriatric psychiatry in Hartford, Conn. She also works as a psychiatric consultant to continuing care retirement organizations and professional groups. Dr. Harris, a former president of the Black Psychiatrists of America, is a Distinguished Fellow of the American Psychiatric Association. Besides psychotherapy, her major clinical interests include geriatrics and the interface between general medicine and psychiatry.

We are into a new year, and among many New Year’s resolutions we hear is the resolution to take off body weight. That people are going for a new start, a chance to begin again, is actually good; it brings new hope and vigor to the issue. But sadly, most Americans making this resolution find themselves starting anew at a weight higher than they were the previous new year when they made the same resolution. Despite ourselves, we diet, exercise, and take off some pounds and then return to our previous behaviors that got us to wanting to take off the pounds in the first place.

Can psychiatry get into the body weight adventure and begin to lead the way to solutions? What I hope to do in this new column, “Weighty Issues,” is to share some of what I have learned in becoming an obesity medicine specialist, and learn from other experts who have been assessing and treating overweight and obesity for years.

I also hope to learn and share what we as psychiatrists are doing to manage our own weight (as many of us sit for a living) and lifestyles.

Coming to terms

About two-thirds of Americans are by medical calculations overweight, with half of that proportion actually medically obese. It is well-known that being overweight is a major risk factor for most of the illnesses that cause morbidity and early death among Americans. But this public health crisis was only classified an illness by the American Medical Association in 2013. What took us so long?

The topic of over body weight and psychiatry has been heavy on my mind for many years. It always puzzled me that psychiatry concentrated on anorexia nervosa, bulimia, and binge eating but was largely not focusing on the issue that was creeping up around us and becoming the major public health concern: that of overweight and obesity.

I knew that we were to concern ourselves only with illness but by ignoring the issue we, along with the rest of medicine, have promoted major, chronic illnesses of diabetes, heart disease, cancer, and so on. Fortunately for us, the AMA declared obesity a medical illness, but unfortunately, the way the reimbursement reads for treating obesity, one must be a sort of primary care physician or surgeon to get paid for the work. To my way of thinking, psychiatrists are the best physicians to be working in the field of overweight and obesity medicine, because we – more than any other medical specialty – understand that thoughts and feelings are involved in behavior. We understand that to be successful long-term in any endeavor, one must understand and harness one’s thoughts and feelings.

Moreover, we, more than physicians in other specialties, understand that the treater’s simple transference and countertransference, and the patient’s transference, can determine the trajectory and outcome of the treatment process. Additionally, psychiatrists regularly see their patients more often and over longer periods of time than do other physicians while developing and maintaining respectful and supportive relationships that can best handle the very personal issue of weight.

Surgery often not the answer

After having been a part of many psychiatric and psychological pre–bariatric surgery screenings over many years and having known many patients, friends, and colleagues who had undergone the different surgical treatments for overweight with complications and/or obesity, only to see them, many years later, larger than they were before the surgical intervention, I began to think that cutting it out was not the only definitive way to get better health measures. I knew that each surgical candidate really meant it when they pledged to follow through indefinitely but that feelings and life had intervened, and those were more powerful than surgery. That led me to think like a psychiatrist, and learn from and keep on learning from the feelings throughout life’s challenges and not like a surgeon, whose view is “once it is cut out, it is finished.”

It even led me to think medically radical thoughts that rapid weight loss through diet and lifestyle intervention, such as the weight loss that is achieved through surgery, could be a very good thing with one major caveat ... long-term intervention (psychiatry, the discipline, knows something about long-term intervention). That kind of thinking led me to try to register for a lifestyle program that was sold out at that time. A course in Obesity Medicine, the crux of the matter, was not sold out. I took one course and was hooked, learning all that I did not know about overweight and obesity, and realizing just how complicated the matter of weight actually is.

In time, I studied and learned more, saw more patients, and became a diplomate of the American Board of Obesity Medicine (ABOM). Of the approximately 1,300 diplomates of the ABOM, only 15 identify as having psychiatry as their primary specialty. The board reports that there may be other psychiatrists who are also boarded in internal medicine or pediatrics or surgery, but specific information is not available.

Those of us who prescribe typical and atypical antipsychotic agents and some of the older and newer antidepressants are familiar with the weight gain that can be attendant to these medications. We also are familiar with metabolic syndrome, which can be associated and our need to follow fasting blood glucose and lipid levels as well as waist circumference, height, and weight.

Many of us also will educate our patients about eating fewer sweets and drinking fewer sugar sweetened beverages, consuming fewer starches, and we will advise our patients to increase their exercise. We may even prescribe metformin if the fasting blood sugar and hemoglobin A1C begin to creep upward. In addition, we are constantly trying to offset the side effects of medications that we prescribe for very serious illnesses. In short, psychiatrists already are in the obesity medicine arena.

Addressing personal challenges

Talking the talk and walking the walk is so important in the area of overweight and obesity. I have struggled with overweight most of my adult life and have been “overnutritioned” – the Chinese term for overweight, off and on during my career in psychiatry. During my obesity medicine studies, I took my own weight and lifestyle seriously, and lost a significant amount of weight. Friends and patients asked me if I were well. Over time, some patients who had been with me for years volunteered how they felt about my voluntary weight loss. Most said that I no longer looked powerful; some said that I looked like a lightweight – not a serious person.

Interestingly, over time, all of my patients who had weight issues of their own began to manage their own weight better, and began to talk about their feelings and relationship to food, exercise, and weight. We have all realized that there is more under that puffy cover than meets the eye and that it insulates a whole host of stuff. Calories in and calories out become a superficial path toward a solution.

Regarding simple transference and countertransference ... many physicians have powerful adverse feelings about patients who are overweight or obese and really struggle with working with these patients. One of my friends, a family medicine specialist, told me that he cannot look at them and has told his staff not to assign those patients to him, because they do not comply and then do not come back to follow up. It is likely that his patients pick up on his disdain, anger, and lack of hope for them, and do not return in order to protect their feelings. Interestingly, this friend has struggled with his own weight throughout his professional life. Perhaps psychiatry could be useful to the myriad of other physicians like my friend who have visceral reactions to patients with weight issues so that the physicians can be kinder to themselves and their patients can receive the care, understanding, and respect that they deserve.

Attaining and maintaining a healthy weight across the life cycles is a complicated thought-, feeling-, and event-filled endeavor. I look forward to sharing basic science, clinical science, research, and anecdotal reports as we explore “Weighty Issues.”

Dr. Harris, a diplomate of the American Board of Obesity Medicine, is in private practice in adult and geriatric psychiatry in Hartford, Conn. She also works as a psychiatric consultant to continuing care retirement organizations and professional groups. Dr. Harris, a former president of the Black Psychiatrists of America, is a Distinguished Fellow of the American Psychiatric Association. Besides psychotherapy, her major clinical interests include geriatrics and the interface between general medicine and psychiatry.

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

• 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
• 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
• 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

• It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
• There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
• It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
• The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

• 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
• 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
• 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

• It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
• There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
• It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
• The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH

Present “hospitalist” in a word association exercise to a wide range of healthcare personnel in clinical and administrative roles, and many would instantly respond with “seven-on/seven-off schedule.”

Some numbers from SHM’s 2014 State of Hospital Medicine report:

• 53.8%: Portion of hospitalist groups using a seven-on/seven-off schedule.
• 182: Median number of shifts worked annually by a full-time hospitalist (standard contract hours, does not include “extra” shifts).
• 65%: Portion of groups having day shifts that are 12.0–13.9 hours in length.

These numbers suggest to me that, at least outside of academia, the standard hospitalist is working 12-hour shifts on a seven-on/seven-off schedule. And that mirrors my experience working on-site with hundreds of hospitalist groups across the country.

In other words, the hospitalist marketplace has spoken unambiguously regarding the favored work schedule. In some ways, it is a defining feature of hospitalist practice. In the same way that a defining characteristic of Millennials is devotion to social media and that air travel is associated with cramped seats, this work schedule is a defining characteristic for hospitalists.

Schedule Benefits? Many …

There is a reason for its popularity: It is simple to understand and operationalize, it provides for good hospitalist-patient continuity, and having every other week off is often cited as a principle reason for becoming a hospitalist (in many cases, it might only take a clerk or administrator a few hours to create a group’s work schedule for a whole year). Many hospitalist groups have followed this schedule for a decade or longer, and while they might have periodically discussed moving to an entirely different model, most have stuck with what they know.

I’m convinced this schedule will be around for many years to come.

Not Ideal in All Respects

Despite this schedule’s popularity, I regularly talk with hospitalists who say it has become very stressful and monotonous. They say they would really like to change to something else but feel stuck by the complexity of alternative models and the difficulty achieving consensus within the group regarding what model offers enough advantages—and acceptable costs—to be worth it.

They cite as shortcomings of the seven-on/seven-off schedule:

• It can be a Herculean task to alter the schedule to arrange a day or two off during the regularly scheduled week. They often give up on the effort, and over time, this can lead to some resentment toward their work.
• There is a tendency to adopt a systole-diastole lifestyle, with no activities other than work during the week on (e.g., no trips to the gym, dinners out with family, etc.) and an effort to move all of these into the week off. They’ll say, “What other profession requires one to shut down their personal life for seven days every other week?”
• It can be difficult to reliably use the seven days off productively. Sometimes it might be better to return to work after only two to four days off if at other times it were easy to arrange more than seven consecutive days off.
• The “switch day” can be difficult for the hospital. Such schedules nearly always are arranged so that all the doctors conclude seven days of work on the same day and are replaced by others the following day. Every hospitalist patient (typically more than half of all patients in the hospital) gets a new doctor on the same day, and the whole hospital runs less efficiently as a result.

Change Your Schedule?

Who am I kidding? Few groups, probably none to be precise, are likely to change their schedule as a result of reading this column. But I’m among what seems to be a small contingent who believe alternative schedules can work. Whether your group decides to pursue a different model should be entirely up to its members, but it is worthwhile to periodically discuss the costs and benefits of your current schedule as well as what other options might be practical. In most cases the discussion will conclude without any significant change, but discussing it periodically might turn up worthwhile small adjustments.

But if your group is ready to make a meaningful change away from a rigid seven-on/seven-off schedule, the first step could be to vary the number of days off. No longer would all in the group switch on the same day; only one doctor would switch at a time (unless there are more than seven day shifts), and that could occur on any day of the week.

To illustrate, let’s say you’re in a group with four day shifts. For this week, Dr. Plant might start Monday after four days off, Dr. Bonham has had 11 days off and starts Tuesday, Dr. Page starts Friday after nine days off, and Dr. Jones starts Saturday after six days off. Each will work seven consecutive day shifts, and the number of off days will vary depending on their own wishes and the needs of the group. This is much more complicated to schedule, but varying the switch day and number of days off between weeks can be good for work-life balance.

Some will quickly identify difficulties, such as how to get the kids’ nanny to match a varying work schedule like this. I know many hospitalists who have done this successfully and are glad they did, but I’m sure there are also many for whom changing to a schedule like this might require moving from their current terrific childcare arrangements to a new one, something that they (justifiably) are unwilling to do.

And if your group successfully moves to a seven-on/X-off schedule (i.e., varied number of days off), you could next think about varying the number of consecutive days worked. Maybe it could range from no fewer than five or six (to preserve reasonable continuity) to as many as 10 or 11 as long as you have the stamina.

I don’t have research proving this would be a better schedule. But my own career, and the experiences of a number of others I’ve spoken with, is enough to convince me it’s worth considering. TH

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH