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A tumultuous and unforgettable year
SHM president bids farewell
As my SHM presidency wraps up, it is a good time to reflect on the past year in hospital medicine. Dominated by COVID-19 preparedness, mitigation, and (now) recovery efforts, the impacts of COVID-19 throughout the medical industry have been profound. For hospital medicine, although we have endured work and home stress unlike anything in recent memory, fortunately a few notably good changes have come about as a result of COVID-19.
Hospitalists have proven that we are extremely capable of adapting to rapidly changing evidence-based practice. The old adage of evidence taking 7 years to become mainstream clinical practice certainly has not been the paradigm during COVID-19. In many cases, clinical care pathways were changing by the week, or even by the day. Usage of SHM’s website, HMX, and educational platforms rose exponentially to keep pace with the changing landscape. Information exchange between and among hospital medicine groups was efficient and effective. This is exactly how it should be, with SHM serving as the catalyst for such information exchange.
Hospitalists were able to shift to telehealth care as the need arose. The use of telehealth is now becoming a core competency for hospitalists around the country, and we are leading the way for other specialists in adoption. COVID-19 enabled not only rapid transformation, but also better payer coverage for the use of all types of telehealth services. SHM will remain a source of training and education in telehealth best practices going forward.
Related, hospitalists also found their programs were being asked to become purveyors for remote monitoring and hospital-at-home programs. Because CMS has allowed some reimbursement for these programs, at least during the public health emergency, hospital medicine programs can more feasibly pursue building and sustaining such programs, and SHM can serve as the hub for best practice exchanges in the field.
The pandemic also created a sizable shift in the mindset of the need and enthusiasm for mainstream maintenance of certification. Although there were already questions about the value of high-stakes exams before the pandemic, both within and outside the medical industry, the pandemic created an immediate need to shift away from such exams. Now, the entire pipeline is questioning the value of these high-stakes exams, such as SATs and ACTs for college admissions, Step 1 exams for medical students, and certification exams for physicians. The pandemic has made us question these milestone exams with more scrutiny and has created a sense of urgency for a change to more adult-learner–focused alternatives. SHM will continue to be at the centerpiece of the discussion, as well as the leader in cultivating educational venues for continuous learning.
So where do we go from here?
I am confident that SHM will continue to pay deep attention to the activities that bring value to hospitalists and support changing practice patterns such as telehealth and hospital-at-home work. Not only will SHM serve as a center for best practices and a conduit for networking and information sharing at the national level – there will be significantly more focus on the support and growth of local chapters. SHM realizes that local chapters are a vital source of networking, education, and pipeline development and will continue to increase the resources to make the chapter programs dynamic and inviting for everyone interested in hospital medicine.
While this presidency year was far different than expected, I have continuously been amazed and delighted with the resiliency and endurance of our hospitalists around the country. We stood out at the front lines of the pandemic, with a mission toward service and a relentless commitment to our patients. Although we still have a long way to go before the pandemic is behind us, I firmly believe we are emerging from the haze stronger and more agile than ever. Thank you for allowing me to serve this incredible organization during such a tumultuous and unforgettable year.
Yours in service.
Dr. Scheurer is a hospitalist and chief quality officer, MUSC Health System, Medical University of South Carolina, Charleston. She is the outgoing president of SHM.
SHM president bids farewell
SHM president bids farewell
As my SHM presidency wraps up, it is a good time to reflect on the past year in hospital medicine. Dominated by COVID-19 preparedness, mitigation, and (now) recovery efforts, the impacts of COVID-19 throughout the medical industry have been profound. For hospital medicine, although we have endured work and home stress unlike anything in recent memory, fortunately a few notably good changes have come about as a result of COVID-19.
Hospitalists have proven that we are extremely capable of adapting to rapidly changing evidence-based practice. The old adage of evidence taking 7 years to become mainstream clinical practice certainly has not been the paradigm during COVID-19. In many cases, clinical care pathways were changing by the week, or even by the day. Usage of SHM’s website, HMX, and educational platforms rose exponentially to keep pace with the changing landscape. Information exchange between and among hospital medicine groups was efficient and effective. This is exactly how it should be, with SHM serving as the catalyst for such information exchange.
Hospitalists were able to shift to telehealth care as the need arose. The use of telehealth is now becoming a core competency for hospitalists around the country, and we are leading the way for other specialists in adoption. COVID-19 enabled not only rapid transformation, but also better payer coverage for the use of all types of telehealth services. SHM will remain a source of training and education in telehealth best practices going forward.
Related, hospitalists also found their programs were being asked to become purveyors for remote monitoring and hospital-at-home programs. Because CMS has allowed some reimbursement for these programs, at least during the public health emergency, hospital medicine programs can more feasibly pursue building and sustaining such programs, and SHM can serve as the hub for best practice exchanges in the field.
The pandemic also created a sizable shift in the mindset of the need and enthusiasm for mainstream maintenance of certification. Although there were already questions about the value of high-stakes exams before the pandemic, both within and outside the medical industry, the pandemic created an immediate need to shift away from such exams. Now, the entire pipeline is questioning the value of these high-stakes exams, such as SATs and ACTs for college admissions, Step 1 exams for medical students, and certification exams for physicians. The pandemic has made us question these milestone exams with more scrutiny and has created a sense of urgency for a change to more adult-learner–focused alternatives. SHM will continue to be at the centerpiece of the discussion, as well as the leader in cultivating educational venues for continuous learning.
So where do we go from here?
I am confident that SHM will continue to pay deep attention to the activities that bring value to hospitalists and support changing practice patterns such as telehealth and hospital-at-home work. Not only will SHM serve as a center for best practices and a conduit for networking and information sharing at the national level – there will be significantly more focus on the support and growth of local chapters. SHM realizes that local chapters are a vital source of networking, education, and pipeline development and will continue to increase the resources to make the chapter programs dynamic and inviting for everyone interested in hospital medicine.
While this presidency year was far different than expected, I have continuously been amazed and delighted with the resiliency and endurance of our hospitalists around the country. We stood out at the front lines of the pandemic, with a mission toward service and a relentless commitment to our patients. Although we still have a long way to go before the pandemic is behind us, I firmly believe we are emerging from the haze stronger and more agile than ever. Thank you for allowing me to serve this incredible organization during such a tumultuous and unforgettable year.
Yours in service.
Dr. Scheurer is a hospitalist and chief quality officer, MUSC Health System, Medical University of South Carolina, Charleston. She is the outgoing president of SHM.
As my SHM presidency wraps up, it is a good time to reflect on the past year in hospital medicine. Dominated by COVID-19 preparedness, mitigation, and (now) recovery efforts, the impacts of COVID-19 throughout the medical industry have been profound. For hospital medicine, although we have endured work and home stress unlike anything in recent memory, fortunately a few notably good changes have come about as a result of COVID-19.
Hospitalists have proven that we are extremely capable of adapting to rapidly changing evidence-based practice. The old adage of evidence taking 7 years to become mainstream clinical practice certainly has not been the paradigm during COVID-19. In many cases, clinical care pathways were changing by the week, or even by the day. Usage of SHM’s website, HMX, and educational platforms rose exponentially to keep pace with the changing landscape. Information exchange between and among hospital medicine groups was efficient and effective. This is exactly how it should be, with SHM serving as the catalyst for such information exchange.
Hospitalists were able to shift to telehealth care as the need arose. The use of telehealth is now becoming a core competency for hospitalists around the country, and we are leading the way for other specialists in adoption. COVID-19 enabled not only rapid transformation, but also better payer coverage for the use of all types of telehealth services. SHM will remain a source of training and education in telehealth best practices going forward.
Related, hospitalists also found their programs were being asked to become purveyors for remote monitoring and hospital-at-home programs. Because CMS has allowed some reimbursement for these programs, at least during the public health emergency, hospital medicine programs can more feasibly pursue building and sustaining such programs, and SHM can serve as the hub for best practice exchanges in the field.
The pandemic also created a sizable shift in the mindset of the need and enthusiasm for mainstream maintenance of certification. Although there were already questions about the value of high-stakes exams before the pandemic, both within and outside the medical industry, the pandemic created an immediate need to shift away from such exams. Now, the entire pipeline is questioning the value of these high-stakes exams, such as SATs and ACTs for college admissions, Step 1 exams for medical students, and certification exams for physicians. The pandemic has made us question these milestone exams with more scrutiny and has created a sense of urgency for a change to more adult-learner–focused alternatives. SHM will continue to be at the centerpiece of the discussion, as well as the leader in cultivating educational venues for continuous learning.
So where do we go from here?
I am confident that SHM will continue to pay deep attention to the activities that bring value to hospitalists and support changing practice patterns such as telehealth and hospital-at-home work. Not only will SHM serve as a center for best practices and a conduit for networking and information sharing at the national level – there will be significantly more focus on the support and growth of local chapters. SHM realizes that local chapters are a vital source of networking, education, and pipeline development and will continue to increase the resources to make the chapter programs dynamic and inviting for everyone interested in hospital medicine.
While this presidency year was far different than expected, I have continuously been amazed and delighted with the resiliency and endurance of our hospitalists around the country. We stood out at the front lines of the pandemic, with a mission toward service and a relentless commitment to our patients. Although we still have a long way to go before the pandemic is behind us, I firmly believe we are emerging from the haze stronger and more agile than ever. Thank you for allowing me to serve this incredible organization during such a tumultuous and unforgettable year.
Yours in service.
Dr. Scheurer is a hospitalist and chief quality officer, MUSC Health System, Medical University of South Carolina, Charleston. She is the outgoing president of SHM.
SHM Converge: New format, fresh content
While we all long for a traditional in-person meeting “like the good old days”, there are some significant advantages to a virtual meeting like Converge.
The most significant advantage is the ability to review more content than ever before, as we offer a combination of live and recorded “on-demand” sessions. This allows for incredible flexibility in garnering “top-shelf” content from hospital medicine experts around the country, without having to choose from competing sessions. We are especially looking forward to new sessions this year focused on COVID-19; diversity, equity, and inclusion; and resilience.
The Converge conference will still be offering networking sessions throughout – even in the virtual conference environment. We consider networking a vital and endearing part of the value equation for SHM members. For example, we now can participate in several Special Interest Forums, since many of us have several niche interests and want to take advantage of more than one of these networking opportunities. We also carefully preserved the signature “Update in Hospital Medicine” session, as well as the scientific abstract poster reception and the Best of Research and Innovation sessions. These are long-term favorites at the annual conference and lend themselves well to virtual transformation. Some of the workshops and special sessions have exclusive audience engagement and are not offered on demand, so signing up early for these sessions is highly recommended.
SHM remains the professional home for hospitalists, and we rely on the annual conference to keep us all informed on current and forward-thinking clinical practice, practice management, leadership, academics, research, and other topics. This is one of many examples of how SHM has been able to pivot to meet the needs of hospitalists throughout the pandemic. Not only have we successfully converted “traditional” meetings into virtual meetings, but we have been able to curate and deliver content faster and more seamlessly than ever before.
Whether via The Hospitalist, the Journal of Hospital Medicine, the SHM website, or our other educational platforms, SHM has remained committed to being the single “source of truth” for all things hospital medicine. Within the tumultuous political landscape of the past year, the SHM advocacy team has been more active and engaged than ever, in advocating for a myriad of hospitalist-related legislative changes. These are just a few of the ways SHM continues to add value to hospitalist members every day.
Although we will certainly miss seeing each other in person, we are confident that the SHM team will meet and exceed expectations on content delivery and will take advantage of the virtual format to improve content access. We look forward to “seeing” you at SHM Converge this year and hope you take advantage of the enhanced delivery and access to an array of amazing content!
Dr. Scheurer is president of the Society of Hospital Medicine. She is a hospitalist and chief quality officer, MUSC Health System, Medical University of South Carolina, Charleston.
While we all long for a traditional in-person meeting “like the good old days”, there are some significant advantages to a virtual meeting like Converge.
The most significant advantage is the ability to review more content than ever before, as we offer a combination of live and recorded “on-demand” sessions. This allows for incredible flexibility in garnering “top-shelf” content from hospital medicine experts around the country, without having to choose from competing sessions. We are especially looking forward to new sessions this year focused on COVID-19; diversity, equity, and inclusion; and resilience.
The Converge conference will still be offering networking sessions throughout – even in the virtual conference environment. We consider networking a vital and endearing part of the value equation for SHM members. For example, we now can participate in several Special Interest Forums, since many of us have several niche interests and want to take advantage of more than one of these networking opportunities. We also carefully preserved the signature “Update in Hospital Medicine” session, as well as the scientific abstract poster reception and the Best of Research and Innovation sessions. These are long-term favorites at the annual conference and lend themselves well to virtual transformation. Some of the workshops and special sessions have exclusive audience engagement and are not offered on demand, so signing up early for these sessions is highly recommended.
SHM remains the professional home for hospitalists, and we rely on the annual conference to keep us all informed on current and forward-thinking clinical practice, practice management, leadership, academics, research, and other topics. This is one of many examples of how SHM has been able to pivot to meet the needs of hospitalists throughout the pandemic. Not only have we successfully converted “traditional” meetings into virtual meetings, but we have been able to curate and deliver content faster and more seamlessly than ever before.
Whether via The Hospitalist, the Journal of Hospital Medicine, the SHM website, or our other educational platforms, SHM has remained committed to being the single “source of truth” for all things hospital medicine. Within the tumultuous political landscape of the past year, the SHM advocacy team has been more active and engaged than ever, in advocating for a myriad of hospitalist-related legislative changes. These are just a few of the ways SHM continues to add value to hospitalist members every day.
Although we will certainly miss seeing each other in person, we are confident that the SHM team will meet and exceed expectations on content delivery and will take advantage of the virtual format to improve content access. We look forward to “seeing” you at SHM Converge this year and hope you take advantage of the enhanced delivery and access to an array of amazing content!
Dr. Scheurer is president of the Society of Hospital Medicine. She is a hospitalist and chief quality officer, MUSC Health System, Medical University of South Carolina, Charleston.
While we all long for a traditional in-person meeting “like the good old days”, there are some significant advantages to a virtual meeting like Converge.
The most significant advantage is the ability to review more content than ever before, as we offer a combination of live and recorded “on-demand” sessions. This allows for incredible flexibility in garnering “top-shelf” content from hospital medicine experts around the country, without having to choose from competing sessions. We are especially looking forward to new sessions this year focused on COVID-19; diversity, equity, and inclusion; and resilience.
The Converge conference will still be offering networking sessions throughout – even in the virtual conference environment. We consider networking a vital and endearing part of the value equation for SHM members. For example, we now can participate in several Special Interest Forums, since many of us have several niche interests and want to take advantage of more than one of these networking opportunities. We also carefully preserved the signature “Update in Hospital Medicine” session, as well as the scientific abstract poster reception and the Best of Research and Innovation sessions. These are long-term favorites at the annual conference and lend themselves well to virtual transformation. Some of the workshops and special sessions have exclusive audience engagement and are not offered on demand, so signing up early for these sessions is highly recommended.
SHM remains the professional home for hospitalists, and we rely on the annual conference to keep us all informed on current and forward-thinking clinical practice, practice management, leadership, academics, research, and other topics. This is one of many examples of how SHM has been able to pivot to meet the needs of hospitalists throughout the pandemic. Not only have we successfully converted “traditional” meetings into virtual meetings, but we have been able to curate and deliver content faster and more seamlessly than ever before.
Whether via The Hospitalist, the Journal of Hospital Medicine, the SHM website, or our other educational platforms, SHM has remained committed to being the single “source of truth” for all things hospital medicine. Within the tumultuous political landscape of the past year, the SHM advocacy team has been more active and engaged than ever, in advocating for a myriad of hospitalist-related legislative changes. These are just a few of the ways SHM continues to add value to hospitalist members every day.
Although we will certainly miss seeing each other in person, we are confident that the SHM team will meet and exceed expectations on content delivery and will take advantage of the virtual format to improve content access. We look forward to “seeing” you at SHM Converge this year and hope you take advantage of the enhanced delivery and access to an array of amazing content!
Dr. Scheurer is president of the Society of Hospital Medicine. She is a hospitalist and chief quality officer, MUSC Health System, Medical University of South Carolina, Charleston.
Leading in crisis
Lessons from the trail
I have learned a lot about crisis management and leadership in the rapidly changing COVID health care environment. I have learned how to make quick and imperfect decisions with limited information, and how to move on swiftly. I have learned how to quickly fade out memories of how we used to run our business, and pivot to unknown and untested delivery modalities. I have learned how to take regulatory standards as guidance, not doctrine. And I have learned how tell longstanding loyal colleagues that they are being laid off.
Many of these leadership challenges are not new, but the rapidity of change and the weight and magnitude of decision making is unparalleled in my relatively short career. In some ways, it reminds me of some solid lessons I have learned over time as a lifetime runner, with many analogies and applications to leadership.
Some people ask me why I run. “You must get a runner’s high.” The truth is, I have never had a runner’s high. I feel every step. In fact, the very nature of running makes a person feel like they are being pulled under water. Runners are typically tachycardic and short of breath the whole time they are running. But what running does allow for is to ignore some of the signals your body is sending, and wholly and completely focus on other things. I often have my most creative and innovative thoughts while running. So that is why I run. But back to the point of what running and leadership have in common – and how lessons learned can translate between the two:
They are both really hard. As I mentioned above, running literally makes you feel like you are drowning. But when you finish running, it is amazing how easy everything else feels! Similar to leadership, it should feel hard, but not too hard. I have seen firsthand the effects of under- and over-delegating, and both are dysfunctional. Good leadership is a blend of being humble and servant, but also ensuring self-care and endurance. It is also important to acknowledge the difficulty of leadership. Dr. Tom Lee, currently chief medical officer at Press Ganey, is a leader I have always admired. He once said, “Leadership can be very lonely.” At the time, I did not quite understand that, but I have come to experience that feeling occasionally. The other aspect of leadership that I find really hard is that often, people’s anger is misdirected at leaders as a natural outlet for that anger. Part of being a leader is enduring such anger, gaining an understanding for it, and doing what you can to help people through it.
They both work better when you are restored. It sounds generic and cliché, but you can’t be a good runner or a good leader when you are totally depleted.
They both require efficiency. When I was running my first marathon, a complete stranger ran up beside me and started giving me advice. I thought it was sort of strange advice at the time, but it turned out to be sound and useful. He noticed my running pattern of “sticking to the road,” and he told me I should rather “run as the crow flies.” What he meant was to run in as straight of a line as possible, regardless of the road, to preserve energy and save steps. He recommended picking a point on the horizon and running toward that point as straight as possible. As he sped off ahead of me in the next mile, his parting words were, “You’ll thank me at mile 24…” To this day, I still use that tactic, which I find very steadying and calming during running. The same can be said for leadership; as you pick a point on the horizon, keep yourself and your team heading toward that point with intense focus, and before you realize it, you’ve reached your destination.
They both require having a goal. That same stranger who gave me advice on running efficiently also asked what my goal was. It caught me off guard a bit, as I realized my only goal was to finish. He encouraged me to make a goal for the run, which could serve as a motivator when the going got tough. This was another piece of lasting advice I have used for both running and for leadership.
They both can be endured by committing to continuous forward motion. Running and leadership both become psychologically much easier when you realize all you really have to do is maintain continuous forward motion. Some days require less effort than others, but I can always convince myself I am capable of some forward motion.
They both are easier if you don’t overthink things. When I first started in a leadership position, I would have moments of anxiety if I thought too hard about what I was responsible for. Similar to running, it works best if you don’t overthink what difficulties it may bring; rather, just put on your shoes and get going.
In the end, leading during COVID is like stepping onto a new trail. Despite the new terrain and foreign path, my prior training and trusty pair of sneakers – like my leadership skills and past experiences – will get me through this journey, one step at a time.
Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.
Lessons from the trail
Lessons from the trail
I have learned a lot about crisis management and leadership in the rapidly changing COVID health care environment. I have learned how to make quick and imperfect decisions with limited information, and how to move on swiftly. I have learned how to quickly fade out memories of how we used to run our business, and pivot to unknown and untested delivery modalities. I have learned how to take regulatory standards as guidance, not doctrine. And I have learned how tell longstanding loyal colleagues that they are being laid off.
Many of these leadership challenges are not new, but the rapidity of change and the weight and magnitude of decision making is unparalleled in my relatively short career. In some ways, it reminds me of some solid lessons I have learned over time as a lifetime runner, with many analogies and applications to leadership.
Some people ask me why I run. “You must get a runner’s high.” The truth is, I have never had a runner’s high. I feel every step. In fact, the very nature of running makes a person feel like they are being pulled under water. Runners are typically tachycardic and short of breath the whole time they are running. But what running does allow for is to ignore some of the signals your body is sending, and wholly and completely focus on other things. I often have my most creative and innovative thoughts while running. So that is why I run. But back to the point of what running and leadership have in common – and how lessons learned can translate between the two:
They are both really hard. As I mentioned above, running literally makes you feel like you are drowning. But when you finish running, it is amazing how easy everything else feels! Similar to leadership, it should feel hard, but not too hard. I have seen firsthand the effects of under- and over-delegating, and both are dysfunctional. Good leadership is a blend of being humble and servant, but also ensuring self-care and endurance. It is also important to acknowledge the difficulty of leadership. Dr. Tom Lee, currently chief medical officer at Press Ganey, is a leader I have always admired. He once said, “Leadership can be very lonely.” At the time, I did not quite understand that, but I have come to experience that feeling occasionally. The other aspect of leadership that I find really hard is that often, people’s anger is misdirected at leaders as a natural outlet for that anger. Part of being a leader is enduring such anger, gaining an understanding for it, and doing what you can to help people through it.
They both work better when you are restored. It sounds generic and cliché, but you can’t be a good runner or a good leader when you are totally depleted.
They both require efficiency. When I was running my first marathon, a complete stranger ran up beside me and started giving me advice. I thought it was sort of strange advice at the time, but it turned out to be sound and useful. He noticed my running pattern of “sticking to the road,” and he told me I should rather “run as the crow flies.” What he meant was to run in as straight of a line as possible, regardless of the road, to preserve energy and save steps. He recommended picking a point on the horizon and running toward that point as straight as possible. As he sped off ahead of me in the next mile, his parting words were, “You’ll thank me at mile 24…” To this day, I still use that tactic, which I find very steadying and calming during running. The same can be said for leadership; as you pick a point on the horizon, keep yourself and your team heading toward that point with intense focus, and before you realize it, you’ve reached your destination.
They both require having a goal. That same stranger who gave me advice on running efficiently also asked what my goal was. It caught me off guard a bit, as I realized my only goal was to finish. He encouraged me to make a goal for the run, which could serve as a motivator when the going got tough. This was another piece of lasting advice I have used for both running and for leadership.
They both can be endured by committing to continuous forward motion. Running and leadership both become psychologically much easier when you realize all you really have to do is maintain continuous forward motion. Some days require less effort than others, but I can always convince myself I am capable of some forward motion.
They both are easier if you don’t overthink things. When I first started in a leadership position, I would have moments of anxiety if I thought too hard about what I was responsible for. Similar to running, it works best if you don’t overthink what difficulties it may bring; rather, just put on your shoes and get going.
In the end, leading during COVID is like stepping onto a new trail. Despite the new terrain and foreign path, my prior training and trusty pair of sneakers – like my leadership skills and past experiences – will get me through this journey, one step at a time.
Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.
I have learned a lot about crisis management and leadership in the rapidly changing COVID health care environment. I have learned how to make quick and imperfect decisions with limited information, and how to move on swiftly. I have learned how to quickly fade out memories of how we used to run our business, and pivot to unknown and untested delivery modalities. I have learned how to take regulatory standards as guidance, not doctrine. And I have learned how tell longstanding loyal colleagues that they are being laid off.
Many of these leadership challenges are not new, but the rapidity of change and the weight and magnitude of decision making is unparalleled in my relatively short career. In some ways, it reminds me of some solid lessons I have learned over time as a lifetime runner, with many analogies and applications to leadership.
Some people ask me why I run. “You must get a runner’s high.” The truth is, I have never had a runner’s high. I feel every step. In fact, the very nature of running makes a person feel like they are being pulled under water. Runners are typically tachycardic and short of breath the whole time they are running. But what running does allow for is to ignore some of the signals your body is sending, and wholly and completely focus on other things. I often have my most creative and innovative thoughts while running. So that is why I run. But back to the point of what running and leadership have in common – and how lessons learned can translate between the two:
They are both really hard. As I mentioned above, running literally makes you feel like you are drowning. But when you finish running, it is amazing how easy everything else feels! Similar to leadership, it should feel hard, but not too hard. I have seen firsthand the effects of under- and over-delegating, and both are dysfunctional. Good leadership is a blend of being humble and servant, but also ensuring self-care and endurance. It is also important to acknowledge the difficulty of leadership. Dr. Tom Lee, currently chief medical officer at Press Ganey, is a leader I have always admired. He once said, “Leadership can be very lonely.” At the time, I did not quite understand that, but I have come to experience that feeling occasionally. The other aspect of leadership that I find really hard is that often, people’s anger is misdirected at leaders as a natural outlet for that anger. Part of being a leader is enduring such anger, gaining an understanding for it, and doing what you can to help people through it.
They both work better when you are restored. It sounds generic and cliché, but you can’t be a good runner or a good leader when you are totally depleted.
They both require efficiency. When I was running my first marathon, a complete stranger ran up beside me and started giving me advice. I thought it was sort of strange advice at the time, but it turned out to be sound and useful. He noticed my running pattern of “sticking to the road,” and he told me I should rather “run as the crow flies.” What he meant was to run in as straight of a line as possible, regardless of the road, to preserve energy and save steps. He recommended picking a point on the horizon and running toward that point as straight as possible. As he sped off ahead of me in the next mile, his parting words were, “You’ll thank me at mile 24…” To this day, I still use that tactic, which I find very steadying and calming during running. The same can be said for leadership; as you pick a point on the horizon, keep yourself and your team heading toward that point with intense focus, and before you realize it, you’ve reached your destination.
They both require having a goal. That same stranger who gave me advice on running efficiently also asked what my goal was. It caught me off guard a bit, as I realized my only goal was to finish. He encouraged me to make a goal for the run, which could serve as a motivator when the going got tough. This was another piece of lasting advice I have used for both running and for leadership.
They both can be endured by committing to continuous forward motion. Running and leadership both become psychologically much easier when you realize all you really have to do is maintain continuous forward motion. Some days require less effort than others, but I can always convince myself I am capable of some forward motion.
They both are easier if you don’t overthink things. When I first started in a leadership position, I would have moments of anxiety if I thought too hard about what I was responsible for. Similar to running, it works best if you don’t overthink what difficulties it may bring; rather, just put on your shoes and get going.
In the end, leading during COVID is like stepping onto a new trail. Despite the new terrain and foreign path, my prior training and trusty pair of sneakers – like my leadership skills and past experiences – will get me through this journey, one step at a time.
Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.
Do hospitalists improve inpatient outcomes?
Long continues the debate on what impact hospitalists have on inpatient outcomes. This issue has been playing out in the medical literature for 20 years, since the coining of the term in 1997. In a recent iteration of the debate, a study was published in JAMA Internal Medicine entitled “Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists.”
The study retrospectively evaluated health care resources and outcomes from over a half-million Medicare beneficiaries hospitalized in 2013 for 20 common diagnosis-related groups, by type of physician provider (hospitalist, their primary care physician, or other generalist). The study found that nonhospitalists used more consultations and had longer lengths of stays, compared with hospitalists. In addition, relative to hospitalists, PCPs were more likely to discharge patients to home, had similar readmission rates, and lower 30-day mortality rates, but generalists were less likely to discharge patients home, had higher readmission rates, and higher mortality rates.
As hospitalists, we need to understand and acknowledge that most of our patients are “brand new” to us, and it is paramount that we use all available resources to gain a deep understanding of the patient in as short a time as possible. For example, ensuring all medical records available are reviewed, at least as much as possible, including a medical list (including a medication reconciliation). Interviewing family members or caregivers is also obviously a “best practice.” As well, having the insight of the PCP in these patients’ care is unquestionably good for us, for the PCP, and for the patient.
With good communication processes and an eye for excellence in care transitions, hospitalists can and should achieve the best outcomes for all of their patients. I look forward to more research in this arena, including a better understanding of the mechanisms by which we can all reliably produce excellent outcomes for the patients we serve.
Read the full post at hospitalleader.org.
Also on The Hospital Leader …
• Locums vs. F/T Hospitalists: Do Temps Stack Up? by Brad Flansbaum, DO, MPH, MHM
• Rounds: Are We Spinning Our Wheels? by Vineet Arora, MD, MPP, MHM
• Up Your Game in APP Integration by Tracy Cardin, ACNP-BC, SFHM
Long continues the debate on what impact hospitalists have on inpatient outcomes. This issue has been playing out in the medical literature for 20 years, since the coining of the term in 1997. In a recent iteration of the debate, a study was published in JAMA Internal Medicine entitled “Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists.”
The study retrospectively evaluated health care resources and outcomes from over a half-million Medicare beneficiaries hospitalized in 2013 for 20 common diagnosis-related groups, by type of physician provider (hospitalist, their primary care physician, or other generalist). The study found that nonhospitalists used more consultations and had longer lengths of stays, compared with hospitalists. In addition, relative to hospitalists, PCPs were more likely to discharge patients to home, had similar readmission rates, and lower 30-day mortality rates, but generalists were less likely to discharge patients home, had higher readmission rates, and higher mortality rates.
As hospitalists, we need to understand and acknowledge that most of our patients are “brand new” to us, and it is paramount that we use all available resources to gain a deep understanding of the patient in as short a time as possible. For example, ensuring all medical records available are reviewed, at least as much as possible, including a medical list (including a medication reconciliation). Interviewing family members or caregivers is also obviously a “best practice.” As well, having the insight of the PCP in these patients’ care is unquestionably good for us, for the PCP, and for the patient.
With good communication processes and an eye for excellence in care transitions, hospitalists can and should achieve the best outcomes for all of their patients. I look forward to more research in this arena, including a better understanding of the mechanisms by which we can all reliably produce excellent outcomes for the patients we serve.
Read the full post at hospitalleader.org.
Also on The Hospital Leader …
• Locums vs. F/T Hospitalists: Do Temps Stack Up? by Brad Flansbaum, DO, MPH, MHM
• Rounds: Are We Spinning Our Wheels? by Vineet Arora, MD, MPP, MHM
• Up Your Game in APP Integration by Tracy Cardin, ACNP-BC, SFHM
Long continues the debate on what impact hospitalists have on inpatient outcomes. This issue has been playing out in the medical literature for 20 years, since the coining of the term in 1997. In a recent iteration of the debate, a study was published in JAMA Internal Medicine entitled “Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists.”
The study retrospectively evaluated health care resources and outcomes from over a half-million Medicare beneficiaries hospitalized in 2013 for 20 common diagnosis-related groups, by type of physician provider (hospitalist, their primary care physician, or other generalist). The study found that nonhospitalists used more consultations and had longer lengths of stays, compared with hospitalists. In addition, relative to hospitalists, PCPs were more likely to discharge patients to home, had similar readmission rates, and lower 30-day mortality rates, but generalists were less likely to discharge patients home, had higher readmission rates, and higher mortality rates.
As hospitalists, we need to understand and acknowledge that most of our patients are “brand new” to us, and it is paramount that we use all available resources to gain a deep understanding of the patient in as short a time as possible. For example, ensuring all medical records available are reviewed, at least as much as possible, including a medical list (including a medication reconciliation). Interviewing family members or caregivers is also obviously a “best practice.” As well, having the insight of the PCP in these patients’ care is unquestionably good for us, for the PCP, and for the patient.
With good communication processes and an eye for excellence in care transitions, hospitalists can and should achieve the best outcomes for all of their patients. I look forward to more research in this arena, including a better understanding of the mechanisms by which we can all reliably produce excellent outcomes for the patients we serve.
Read the full post at hospitalleader.org.
Also on The Hospital Leader …
• Locums vs. F/T Hospitalists: Do Temps Stack Up? by Brad Flansbaum, DO, MPH, MHM
• Rounds: Are We Spinning Our Wheels? by Vineet Arora, MD, MPP, MHM
• Up Your Game in APP Integration by Tracy Cardin, ACNP-BC, SFHM
The role of NPs and PAs in hospital medicine programs
Background and growth
Hospitalist nurse practitioner (NP) and physician assistant (PA) providers have been a growing and evolving part of the inpatient medical workforce, seemingly since the inception of hospital medicine. Given the growth of these disciplines within hospital medicine, at this juncture it is helpful to look at this journey, to see what roles these providers have been serving, and to consider newer and novel trends in how NPs and PAs are being weaved into hospital medicine programs.
The drivers for growth in this provider population are not unlike those of physician hospitalists. The same milieu that provided inroads for physicians in hospital-based care have led the way for increased use of NP/PA providers. An aging physician workforce, residency work hour reforms, increasing complexity of patients and systems on the inpatient side, and the recognition that caring for inpatients is a specialty vastly different from the role of internist in primary care have all impacted the numbers of NPs and PAs in this arena.
• 2007 Today’s Hospitalist article: “Midlevels make a rocky entrance into hospital medicine”1
• 2009 ACP Hospitalist article: “When hiring midlevels, proceed with caution”2
These titles reflect the uncertainty at the time in how best to utilize NP/PA providers in hospital medicine (as well as an unfashionable vocabulary). The numbers at the time tell a similar story. In the Society of Hospital Medicine survey in 2007-2008, about 29% and 21% of hospital medicine practices utilized NPs and PAs, respectively. However, by 2014 about 50% of Veterans Affairs inpatient medical services deployed NP/PA providers, and most recent data from the Society of Hospital Medicine reveal that about 63% of groups use these advanced practice providers (APPs), with higher numbers in pediatric programs. Clearly there is evolving growth and enthusiasm for NP/PAs in hospital medicine.
Program models
Determining how best to use NP/PAs in hospital medicine programs has had a similar evolution. Reviewing past articles addressing these issues, one can see that there has been clear migration; initially NP/PAs were primarily hired to assist with late-afternoon admission surges, with about 60% of the APP workload being utilized to admit in 2007. Their role has continued to grow and change, much as hospitalist practices have; current program models consist of a few major types, with some novel models coming to the fore.
Another model is use of an NP/PA in an observation unit or with lower acuity observation patients. The majority of the management of the patients is completed and billed by the APP, with the physician available for backup. This hits the “sweet spot,” utilizing the right provider with the right skill set for the right patient. The program has to account for some reimbursement or compensation for the physician oversight time, but it is a very efficient use of APPs.
The third major deployment of APPs is with admissions. Many groups use APPs to admit into the late afternoon and evening, getting patients “tucked in,” including starting diagnostic work-ups and treatment plans. The physician hospitalist then evaluates the patient the next day and often bills for the admission. This model works in situations where the patient work-up is dependent on lab testing, imaging, or other diagnostic testing to understand and plan for the “arc” of the hospitalization; or in situations where the diagnosis is clear, but the patient needs time with treatment to determine response. The downside of this model is long-term job satisfaction for the APP (although some programs have them rotate through such a model at intervals).
Another area where APPs have made strong inroads is that of comanagement services. The NP or PA develops a long-term relationship with a surgical comanagement team, and is often highly engaged and extremely appreciated for managing chronic conditions such as hypertension and diabetes. This can be a very satisfying model for both teams. The NP/PA usually bills independently for these encounters.
APPS are also used in cross coverage and triage roles, allowing the day teams to focus on their primary patients. In a triage role, they can interface with the emergency department, providing a semi-neutral “mediator” for patient disposition.
On the more novel end of the spectrum, there is growth in more independent roles for APP hospitalists. Some groups are having success at using the paired rounding or dyad model, but having the physician see the patient every third day. This is most successful where there is strong onboarding and deep clarity for when to contact the backup physician. There are some data to support the effectiveness of this model, most recently in the Journal of Clinical Outcomes Management.3
Critical access hospitals are also having success in deploying APPs in a very independent role, staffing these hospitals at night. Smaller, rural hospitals with aging medical staff have learned to maximize the scope of practice of their APPs to remain viable and provide care for inpatients. This can be a very successful model for APPs working at the maximum scope of their practice. In addition, the use of telemedicine has been implemented to allow for remote physician backup. This may be a rapidly growing arm to hospital medicine practices in the future.
Ongoing barriers
There are many barriers to maximizing the scope of practice and efficiency of APPs in hospital medicine. They range from the “macro” to the “micro.”
On the larger stage, Medicare requires that home care orders be signed by an attending physician, which can be inefficient and difficult to accomplish. Other payers may have somewhat arcane statutes that limit billing practices, and state practice limitations vary widely. Although 22 states now allow for independent practice for NPs, other states may have a very restrictive practice environment that can impede creative care delivery models. But regardless of how liberal a practice the state allows, a hospital’s medical bylaws can still restrict the day-to-day practice of APPs. And those restrictive bylaws are emblematic of a more constant and corporeal barrier to APP practice, that of medical staff culture.
If there are physicians on the staff who fear that utilization of NP/PA providers will lead to a decay in the quality of care, or who feel threatened by the use of APPs, that can create a local stopgap to maximizing utilization of APPs. In addition, hospitalist physicians and leaders may lack knowledge or experience in APP practice. APPs take more time to successfully onboard than physicians; without clear expectations or road maps to accomplish this onboarding, leaders may feel that APP integration doesn’t work. And one bad experience can create long-term barriers for future practices.
Other barriers are the lack of standardized rigor and vigor in graduate education programs (in both educational and clinical experiences). This results in variation in the quality of NP/PA providers at graduation. Knowledge gaps may be perceived as incompetence, rather than just a lack of experience. There is a certificate for added qualification in hospital medicine for PA providers (which includes a specialty exam), and there is an acute care focus for NPs in training; however, there is no standardized licensure to ensure hospital medicine competency, creating a quagmire for hospitalist leaders who desire demonstrable competence of these providers.
Another barrier for some programs is financial; physicians may not want to give up their RVUs to an NP/PA provider. This can really inhibit a more independent role for the APP. It is important that financial incentives align with all members of the practice working at maximum scope.
Summary and future
In summary, the role of PA/NP in hospital medicine has continued to grow and evolve, to meet the needs of the industry. This includes an increase in the scope and independence of APPs, including the use of telehealth for required oversight. As a specialty, it is imperative that we continue to research APP model effectiveness, embrace innovative delivery models, and support effective onboarding and career development opportunities for our NP/PA providers.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Ms. Cardin is vice president, Advanced Practice Providers, at Sound Physicians, and is a member of SHM’s Board of Directors.
References
1. “Midlevels make a rocky entrance into hospital medicine,” by Bonnie Darves, Today’s Hospitalist, January 2007.
2. “When hiring midlevels, proceed with caution,” by Jessica Berthold, ACP Hospitalist, April 2009.
3. “A Comparison of Conventional and Expanded Physician Assistant Hospitalist Staffing Models at a Community Hospital,” J Clin Outcomes Manag. 2016 Oct 1;23[10]:455-61.
Background and growth
Hospitalist nurse practitioner (NP) and physician assistant (PA) providers have been a growing and evolving part of the inpatient medical workforce, seemingly since the inception of hospital medicine. Given the growth of these disciplines within hospital medicine, at this juncture it is helpful to look at this journey, to see what roles these providers have been serving, and to consider newer and novel trends in how NPs and PAs are being weaved into hospital medicine programs.
The drivers for growth in this provider population are not unlike those of physician hospitalists. The same milieu that provided inroads for physicians in hospital-based care have led the way for increased use of NP/PA providers. An aging physician workforce, residency work hour reforms, increasing complexity of patients and systems on the inpatient side, and the recognition that caring for inpatients is a specialty vastly different from the role of internist in primary care have all impacted the numbers of NPs and PAs in this arena.
• 2007 Today’s Hospitalist article: “Midlevels make a rocky entrance into hospital medicine”1
• 2009 ACP Hospitalist article: “When hiring midlevels, proceed with caution”2
These titles reflect the uncertainty at the time in how best to utilize NP/PA providers in hospital medicine (as well as an unfashionable vocabulary). The numbers at the time tell a similar story. In the Society of Hospital Medicine survey in 2007-2008, about 29% and 21% of hospital medicine practices utilized NPs and PAs, respectively. However, by 2014 about 50% of Veterans Affairs inpatient medical services deployed NP/PA providers, and most recent data from the Society of Hospital Medicine reveal that about 63% of groups use these advanced practice providers (APPs), with higher numbers in pediatric programs. Clearly there is evolving growth and enthusiasm for NP/PAs in hospital medicine.
Program models
Determining how best to use NP/PAs in hospital medicine programs has had a similar evolution. Reviewing past articles addressing these issues, one can see that there has been clear migration; initially NP/PAs were primarily hired to assist with late-afternoon admission surges, with about 60% of the APP workload being utilized to admit in 2007. Their role has continued to grow and change, much as hospitalist practices have; current program models consist of a few major types, with some novel models coming to the fore.
Another model is use of an NP/PA in an observation unit or with lower acuity observation patients. The majority of the management of the patients is completed and billed by the APP, with the physician available for backup. This hits the “sweet spot,” utilizing the right provider with the right skill set for the right patient. The program has to account for some reimbursement or compensation for the physician oversight time, but it is a very efficient use of APPs.
The third major deployment of APPs is with admissions. Many groups use APPs to admit into the late afternoon and evening, getting patients “tucked in,” including starting diagnostic work-ups and treatment plans. The physician hospitalist then evaluates the patient the next day and often bills for the admission. This model works in situations where the patient work-up is dependent on lab testing, imaging, or other diagnostic testing to understand and plan for the “arc” of the hospitalization; or in situations where the diagnosis is clear, but the patient needs time with treatment to determine response. The downside of this model is long-term job satisfaction for the APP (although some programs have them rotate through such a model at intervals).
Another area where APPs have made strong inroads is that of comanagement services. The NP or PA develops a long-term relationship with a surgical comanagement team, and is often highly engaged and extremely appreciated for managing chronic conditions such as hypertension and diabetes. This can be a very satisfying model for both teams. The NP/PA usually bills independently for these encounters.
APPS are also used in cross coverage and triage roles, allowing the day teams to focus on their primary patients. In a triage role, they can interface with the emergency department, providing a semi-neutral “mediator” for patient disposition.
On the more novel end of the spectrum, there is growth in more independent roles for APP hospitalists. Some groups are having success at using the paired rounding or dyad model, but having the physician see the patient every third day. This is most successful where there is strong onboarding and deep clarity for when to contact the backup physician. There are some data to support the effectiveness of this model, most recently in the Journal of Clinical Outcomes Management.3
Critical access hospitals are also having success in deploying APPs in a very independent role, staffing these hospitals at night. Smaller, rural hospitals with aging medical staff have learned to maximize the scope of practice of their APPs to remain viable and provide care for inpatients. This can be a very successful model for APPs working at the maximum scope of their practice. In addition, the use of telemedicine has been implemented to allow for remote physician backup. This may be a rapidly growing arm to hospital medicine practices in the future.
Ongoing barriers
There are many barriers to maximizing the scope of practice and efficiency of APPs in hospital medicine. They range from the “macro” to the “micro.”
On the larger stage, Medicare requires that home care orders be signed by an attending physician, which can be inefficient and difficult to accomplish. Other payers may have somewhat arcane statutes that limit billing practices, and state practice limitations vary widely. Although 22 states now allow for independent practice for NPs, other states may have a very restrictive practice environment that can impede creative care delivery models. But regardless of how liberal a practice the state allows, a hospital’s medical bylaws can still restrict the day-to-day practice of APPs. And those restrictive bylaws are emblematic of a more constant and corporeal barrier to APP practice, that of medical staff culture.
If there are physicians on the staff who fear that utilization of NP/PA providers will lead to a decay in the quality of care, or who feel threatened by the use of APPs, that can create a local stopgap to maximizing utilization of APPs. In addition, hospitalist physicians and leaders may lack knowledge or experience in APP practice. APPs take more time to successfully onboard than physicians; without clear expectations or road maps to accomplish this onboarding, leaders may feel that APP integration doesn’t work. And one bad experience can create long-term barriers for future practices.
Other barriers are the lack of standardized rigor and vigor in graduate education programs (in both educational and clinical experiences). This results in variation in the quality of NP/PA providers at graduation. Knowledge gaps may be perceived as incompetence, rather than just a lack of experience. There is a certificate for added qualification in hospital medicine for PA providers (which includes a specialty exam), and there is an acute care focus for NPs in training; however, there is no standardized licensure to ensure hospital medicine competency, creating a quagmire for hospitalist leaders who desire demonstrable competence of these providers.
Another barrier for some programs is financial; physicians may not want to give up their RVUs to an NP/PA provider. This can really inhibit a more independent role for the APP. It is important that financial incentives align with all members of the practice working at maximum scope.
Summary and future
In summary, the role of PA/NP in hospital medicine has continued to grow and evolve, to meet the needs of the industry. This includes an increase in the scope and independence of APPs, including the use of telehealth for required oversight. As a specialty, it is imperative that we continue to research APP model effectiveness, embrace innovative delivery models, and support effective onboarding and career development opportunities for our NP/PA providers.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Ms. Cardin is vice president, Advanced Practice Providers, at Sound Physicians, and is a member of SHM’s Board of Directors.
References
1. “Midlevels make a rocky entrance into hospital medicine,” by Bonnie Darves, Today’s Hospitalist, January 2007.
2. “When hiring midlevels, proceed with caution,” by Jessica Berthold, ACP Hospitalist, April 2009.
3. “A Comparison of Conventional and Expanded Physician Assistant Hospitalist Staffing Models at a Community Hospital,” J Clin Outcomes Manag. 2016 Oct 1;23[10]:455-61.
Background and growth
Hospitalist nurse practitioner (NP) and physician assistant (PA) providers have been a growing and evolving part of the inpatient medical workforce, seemingly since the inception of hospital medicine. Given the growth of these disciplines within hospital medicine, at this juncture it is helpful to look at this journey, to see what roles these providers have been serving, and to consider newer and novel trends in how NPs and PAs are being weaved into hospital medicine programs.
The drivers for growth in this provider population are not unlike those of physician hospitalists. The same milieu that provided inroads for physicians in hospital-based care have led the way for increased use of NP/PA providers. An aging physician workforce, residency work hour reforms, increasing complexity of patients and systems on the inpatient side, and the recognition that caring for inpatients is a specialty vastly different from the role of internist in primary care have all impacted the numbers of NPs and PAs in this arena.
• 2007 Today’s Hospitalist article: “Midlevels make a rocky entrance into hospital medicine”1
• 2009 ACP Hospitalist article: “When hiring midlevels, proceed with caution”2
These titles reflect the uncertainty at the time in how best to utilize NP/PA providers in hospital medicine (as well as an unfashionable vocabulary). The numbers at the time tell a similar story. In the Society of Hospital Medicine survey in 2007-2008, about 29% and 21% of hospital medicine practices utilized NPs and PAs, respectively. However, by 2014 about 50% of Veterans Affairs inpatient medical services deployed NP/PA providers, and most recent data from the Society of Hospital Medicine reveal that about 63% of groups use these advanced practice providers (APPs), with higher numbers in pediatric programs. Clearly there is evolving growth and enthusiasm for NP/PAs in hospital medicine.
Program models
Determining how best to use NP/PAs in hospital medicine programs has had a similar evolution. Reviewing past articles addressing these issues, one can see that there has been clear migration; initially NP/PAs were primarily hired to assist with late-afternoon admission surges, with about 60% of the APP workload being utilized to admit in 2007. Their role has continued to grow and change, much as hospitalist practices have; current program models consist of a few major types, with some novel models coming to the fore.
Another model is use of an NP/PA in an observation unit or with lower acuity observation patients. The majority of the management of the patients is completed and billed by the APP, with the physician available for backup. This hits the “sweet spot,” utilizing the right provider with the right skill set for the right patient. The program has to account for some reimbursement or compensation for the physician oversight time, but it is a very efficient use of APPs.
The third major deployment of APPs is with admissions. Many groups use APPs to admit into the late afternoon and evening, getting patients “tucked in,” including starting diagnostic work-ups and treatment plans. The physician hospitalist then evaluates the patient the next day and often bills for the admission. This model works in situations where the patient work-up is dependent on lab testing, imaging, or other diagnostic testing to understand and plan for the “arc” of the hospitalization; or in situations where the diagnosis is clear, but the patient needs time with treatment to determine response. The downside of this model is long-term job satisfaction for the APP (although some programs have them rotate through such a model at intervals).
Another area where APPs have made strong inroads is that of comanagement services. The NP or PA develops a long-term relationship with a surgical comanagement team, and is often highly engaged and extremely appreciated for managing chronic conditions such as hypertension and diabetes. This can be a very satisfying model for both teams. The NP/PA usually bills independently for these encounters.
APPS are also used in cross coverage and triage roles, allowing the day teams to focus on their primary patients. In a triage role, they can interface with the emergency department, providing a semi-neutral “mediator” for patient disposition.
On the more novel end of the spectrum, there is growth in more independent roles for APP hospitalists. Some groups are having success at using the paired rounding or dyad model, but having the physician see the patient every third day. This is most successful where there is strong onboarding and deep clarity for when to contact the backup physician. There are some data to support the effectiveness of this model, most recently in the Journal of Clinical Outcomes Management.3
Critical access hospitals are also having success in deploying APPs in a very independent role, staffing these hospitals at night. Smaller, rural hospitals with aging medical staff have learned to maximize the scope of practice of their APPs to remain viable and provide care for inpatients. This can be a very successful model for APPs working at the maximum scope of their practice. In addition, the use of telemedicine has been implemented to allow for remote physician backup. This may be a rapidly growing arm to hospital medicine practices in the future.
Ongoing barriers
There are many barriers to maximizing the scope of practice and efficiency of APPs in hospital medicine. They range from the “macro” to the “micro.”
On the larger stage, Medicare requires that home care orders be signed by an attending physician, which can be inefficient and difficult to accomplish. Other payers may have somewhat arcane statutes that limit billing practices, and state practice limitations vary widely. Although 22 states now allow for independent practice for NPs, other states may have a very restrictive practice environment that can impede creative care delivery models. But regardless of how liberal a practice the state allows, a hospital’s medical bylaws can still restrict the day-to-day practice of APPs. And those restrictive bylaws are emblematic of a more constant and corporeal barrier to APP practice, that of medical staff culture.
If there are physicians on the staff who fear that utilization of NP/PA providers will lead to a decay in the quality of care, or who feel threatened by the use of APPs, that can create a local stopgap to maximizing utilization of APPs. In addition, hospitalist physicians and leaders may lack knowledge or experience in APP practice. APPs take more time to successfully onboard than physicians; without clear expectations or road maps to accomplish this onboarding, leaders may feel that APP integration doesn’t work. And one bad experience can create long-term barriers for future practices.
Other barriers are the lack of standardized rigor and vigor in graduate education programs (in both educational and clinical experiences). This results in variation in the quality of NP/PA providers at graduation. Knowledge gaps may be perceived as incompetence, rather than just a lack of experience. There is a certificate for added qualification in hospital medicine for PA providers (which includes a specialty exam), and there is an acute care focus for NPs in training; however, there is no standardized licensure to ensure hospital medicine competency, creating a quagmire for hospitalist leaders who desire demonstrable competence of these providers.
Another barrier for some programs is financial; physicians may not want to give up their RVUs to an NP/PA provider. This can really inhibit a more independent role for the APP. It is important that financial incentives align with all members of the practice working at maximum scope.
Summary and future
In summary, the role of PA/NP in hospital medicine has continued to grow and evolve, to meet the needs of the industry. This includes an increase in the scope and independence of APPs, including the use of telehealth for required oversight. As a specialty, it is imperative that we continue to research APP model effectiveness, embrace innovative delivery models, and support effective onboarding and career development opportunities for our NP/PA providers.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Ms. Cardin is vice president, Advanced Practice Providers, at Sound Physicians, and is a member of SHM’s Board of Directors.
References
1. “Midlevels make a rocky entrance into hospital medicine,” by Bonnie Darves, Today’s Hospitalist, January 2007.
2. “When hiring midlevels, proceed with caution,” by Jessica Berthold, ACP Hospitalist, April 2009.
3. “A Comparison of Conventional and Expanded Physician Assistant Hospitalist Staffing Models at a Community Hospital,” J Clin Outcomes Manag. 2016 Oct 1;23[10]:455-61.
Sneak Peak: The Hospital Leader Blog “The Impact of Hospital Design on Health – for Patients AND Providers”
I was rounding on the inpatient general medicine teaching service last weekend and offered to meet my team of students and residents in the “resident library” on Saturday morning. (Although it holds the name “library,” there were no books or periodicals to be seen.) I had not been in the library for many months and was struck by a few things as I entered. 
It is a dimly lit space, lined on three of the four walls with rickety desks and desktop computers all facing the walls. The walls are painted an off-white color with innumerable dings and nicks, presumably accumulated over the course of years. There was a string of garland in the shape of a Christmas tree pinned to the wall (P.S. It is March), the entire left side of which was sagging and misshapen. There were various tattered and coffee-stained papers scattered haphazardly throughout the room, including what appeared to be progress notes and test results printed from the EHR; a few worn ECGs; a telemetry strip; even a few (REALLY old, no doubt) chest x-ray films. Lining the fourth wall was a large foldable table, topped with crumbs and food scraps, a half-eaten chocolate Bundt cake, and scattered napkins and utensils, some of which appeared to be used. The one exterior-facing wall had a row of windows with crinkled blinds, some completely closed, others opened at awkward angles and seemingly stuck in place. There was a cadre of chairs in the room, none matching, all in various stages of disrepair, with one completely missing an armrest and another tucked in the corner, probably needing the addition of a handwritten sign “BRokEn.”
This library is a place where the students, interns, and residents go for a bit of a safe haven. They can take their coats off, sit down, have their own computer space, answer pages, and complain about their woes. They can bounce questions off each other, vent frustrations, find the humor in a situation, and just be themselves. So,But what struck me about their sanctuary is that it is totally and utterly depressing. And it was as if they didn’t even notice the chaos and filth laying everywhere around them. I find it impossible to believe that it does not have an effect on their mood and outlook. Although we are all social animals, and we have a real need to congregate and connect with one another, is this really the best environment to do that?
Read the full text of this blog post at hospitalleader.org.
Dr. Scheurer is a clinical hospitalist and the medical director of quality and safety at the Medical University of South Carolina in Charleston.
Also on The Hospital Leader…
- Should Overuse Be Considered an Adverse Event By Chris Moriates, MD
- Pulling the Welcome Mat Out from Under Our Colleagues By Brett Hendel-Paterson, MD
- The Upside of Anger By Tracy Cardin, ACNP-BC, SFHM
- Does Your Onboarding Process Really Get Folks on Board? By Leslie Flores, MH, SFHM
- A GIF Is Worth 3000 Words: Introducing #Visual Abstract for #JHMChat By Charlie Wray, DO
I was rounding on the inpatient general medicine teaching service last weekend and offered to meet my team of students and residents in the “resident library” on Saturday morning. (Although it holds the name “library,” there were no books or periodicals to be seen.) I had not been in the library for many months and was struck by a few things as I entered.
It is a dimly lit space, lined on three of the four walls with rickety desks and desktop computers all facing the walls. The walls are painted an off-white color with innumerable dings and nicks, presumably accumulated over the course of years. There was a string of garland in the shape of a Christmas tree pinned to the wall (P.S. It is March), the entire left side of which was sagging and misshapen. There were various tattered and coffee-stained papers scattered haphazardly throughout the room, including what appeared to be progress notes and test results printed from the EHR; a few worn ECGs; a telemetry strip; even a few (REALLY old, no doubt) chest x-ray films. Lining the fourth wall was a large foldable table, topped with crumbs and food scraps, a half-eaten chocolate Bundt cake, and scattered napkins and utensils, some of which appeared to be used. The one exterior-facing wall had a row of windows with crinkled blinds, some completely closed, others opened at awkward angles and seemingly stuck in place. There was a cadre of chairs in the room, none matching, all in various stages of disrepair, with one completely missing an armrest and another tucked in the corner, probably needing the addition of a handwritten sign “BRokEn.”
This library is a place where the students, interns, and residents go for a bit of a safe haven. They can take their coats off, sit down, have their own computer space, answer pages, and complain about their woes. They can bounce questions off each other, vent frustrations, find the humor in a situation, and just be themselves. So,But what struck me about their sanctuary is that it is totally and utterly depressing. And it was as if they didn’t even notice the chaos and filth laying everywhere around them. I find it impossible to believe that it does not have an effect on their mood and outlook. Although we are all social animals, and we have a real need to congregate and connect with one another, is this really the best environment to do that?
Read the full text of this blog post at hospitalleader.org.
Dr. Scheurer is a clinical hospitalist and the medical director of quality and safety at the Medical University of South Carolina in Charleston.
Also on The Hospital Leader…
- Should Overuse Be Considered an Adverse Event By Chris Moriates, MD
- Pulling the Welcome Mat Out from Under Our Colleagues By Brett Hendel-Paterson, MD
- The Upside of Anger By Tracy Cardin, ACNP-BC, SFHM
- Does Your Onboarding Process Really Get Folks on Board? By Leslie Flores, MH, SFHM
- A GIF Is Worth 3000 Words: Introducing #Visual Abstract for #JHMChat By Charlie Wray, DO
I was rounding on the inpatient general medicine teaching service last weekend and offered to meet my team of students and residents in the “resident library” on Saturday morning. (Although it holds the name “library,” there were no books or periodicals to be seen.) I had not been in the library for many months and was struck by a few things as I entered.
It is a dimly lit space, lined on three of the four walls with rickety desks and desktop computers all facing the walls. The walls are painted an off-white color with innumerable dings and nicks, presumably accumulated over the course of years. There was a string of garland in the shape of a Christmas tree pinned to the wall (P.S. It is March), the entire left side of which was sagging and misshapen. There were various tattered and coffee-stained papers scattered haphazardly throughout the room, including what appeared to be progress notes and test results printed from the EHR; a few worn ECGs; a telemetry strip; even a few (REALLY old, no doubt) chest x-ray films. Lining the fourth wall was a large foldable table, topped with crumbs and food scraps, a half-eaten chocolate Bundt cake, and scattered napkins and utensils, some of which appeared to be used. The one exterior-facing wall had a row of windows with crinkled blinds, some completely closed, others opened at awkward angles and seemingly stuck in place. There was a cadre of chairs in the room, none matching, all in various stages of disrepair, with one completely missing an armrest and another tucked in the corner, probably needing the addition of a handwritten sign “BRokEn.”
This library is a place where the students, interns, and residents go for a bit of a safe haven. They can take their coats off, sit down, have their own computer space, answer pages, and complain about their woes. They can bounce questions off each other, vent frustrations, find the humor in a situation, and just be themselves. So,But what struck me about their sanctuary is that it is totally and utterly depressing. And it was as if they didn’t even notice the chaos and filth laying everywhere around them. I find it impossible to believe that it does not have an effect on their mood and outlook. Although we are all social animals, and we have a real need to congregate and connect with one another, is this really the best environment to do that?
Read the full text of this blog post at hospitalleader.org.
Dr. Scheurer is a clinical hospitalist and the medical director of quality and safety at the Medical University of South Carolina in Charleston.
Also on The Hospital Leader…
- Should Overuse Be Considered an Adverse Event By Chris Moriates, MD
- Pulling the Welcome Mat Out from Under Our Colleagues By Brett Hendel-Paterson, MD
- The Upside of Anger By Tracy Cardin, ACNP-BC, SFHM
- Does Your Onboarding Process Really Get Folks on Board? By Leslie Flores, MH, SFHM
- A GIF Is Worth 3000 Words: Introducing #Visual Abstract for #JHMChat By Charlie Wray, DO
QUIZ: What is the Rate of Postoperative Atrial Fibrillation after Non-Cardiac Surgery?
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[WpProQuiz 16]
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Test Your Knowledge: Likelihood Ratios for Differentiating Cirrhotic vs. Non-Cirrhotic Liver Disease
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Quality of Healthcare Systems Depends on People Caring Within
The experience I describe here is an acute illness that my family experienced. Aside from the actual illness, most of the story will not sound surprising or unique to most of you. It is a story about traversing the medical system to get care for my mom, an elderly patient with Alzheimer’s, over the course of three weeks. It is a story about miscommunications and fumbled handoffs, and complex insurance and payments systems that drive decision-making.
In this column, I aim only to describe our experience, which was both predictable and disappointing, within the healthcare system that we all own.
The Background
Sheila is a 76-year-old Caucasian female with a history of well-controlled hypertension and hyperlipidemia and moderate-stage Alzheimer’s disease, diagnosed about six years ago. She has resided in an assisted living facility for about three years and is still relatively independent in her activities of daily living (ADLs). She has remained relatively healthy and active despite her continuously progressive Alzheimer’s.
Her acute illness started when she developed diarrhea that was moderate in volume and frequency. Over the course of several days, the diarrhea significantly affected her sleep and activities, and she became more confused and essentially confined to her room. By day five, she was visibly dehydrated, with dry, cracked lips and skin tenting. Her daughter, Tara, brought her to the ED in the hospital at which her PCP was on staff. During the eight-hour ED stay, Sheila was rehydrated and was able to keep oral fluids down. Her blood work was normal, although the staff were unable to collect a stool sample. Sheila was discharged with instructions to see her PCP within a few days. No one from the ED contacted the PCP, and no one was able to set up a follow-up appointment.
The next day the diarrhea continued, so Tara contacted the PCP. The office staff noted that their next available appointment was in five days. Tara took that appointment and continued to help her mom with symptom management. Over the next several days, the diarrhea continued and the dehydration worsened again, so Tara took her back to the same ED, where they reassured her that the labs were normal, sent a stool sample off for testing, rehydrated her, and sent her home again. On the discharge paperwork, the ED physician noted that they had “set up home health nursing” and instructed a follow-up with Sheila’s PCP.
The next day, Tara contacted the PCP to check on the upcoming appointment, get advice on what to do, and see when the home health nurse would arrive. The PCP office confirmed the upcoming appointment in two days, told her to continue what she was doing, and said they did not know anything of the home health order and that she should contact the ED to clarify. When she contacted the ED, staff there told her the PCP would have to order the home health; Tara then called the PCP again, and he said he could not order home health, given the fact that he had not yet seen Sheila or her ED record. Tara asked a logical question, “But don’t you have the ED records? That is your hospital, right?”
The same cycle ensued over the next few days—now two weeks into the illness—and Sheila started to require increasing assistance with all of her ADLs, including toileting and showering, along with constant supervision to ensure hydration. The family pieced together as much help as possible. Several days later, on a Thursday night, the dehydration was again obvious, so Tara took her to another ED, given the lack of assistance received from the first two ED visits. In this ED, after evaluation, they admitted Sheila for observation. The family again pieced together 24/7 coverage for the hospital stay. The next day, Sheila continued to have diarrhea, now with vomiting. The ED hydrated her and relieved her vomiting and diarrhea with medications.
Because she was in observation, the hospitalist informed the family that he had written a discharge order. The family requested more time, given the fact that she was extremely confused, was hallucinating, and had not kept anything down by mouth; the hospitalist then changed Sheila to inpatient status for ongoing care. By Saturday, the vomiting and diarrhea were much better controlled with medications, but she had not taken anything by mouth other than a few sips of liquid. She was given a regular diet and kept a few bites down. The rounding hospitalist (the third in three days) told Tara he had consulted gastroenterology but that they were no longer needed and Sheila could be discharged. Tara requested that they fulfill the GI consult instead of discharging Sheila, given the length of time of the illness (now almost three weeks), the fact that she was nowhere near her baseline status, and the lack of diagnosis.
In the meantime, when one of the nurses from the assisted living facility called Tara to check on Sheila, she pointed out that she had noticed her mother’s Alzheimer’s medication “looked different” starting about three weeks ago, which coincided with the onset of the diarrhea. With this information, the GI consultant took a good history, looked at the imaging and lab testing, and told the family he strongly suspected the diarrhea had been caused by a change to generic from brand name, a decision that had been made due to the cost of brand name. He recommended stopping the medication, and, if no improvement was seen in the diarrhea within 48 hours, he would expand his workup.
The next day, a Sunday, the same hospitalist rounded early and wrote discharge orders. When Tara’s sister, Michelle, arrived, the nurse told her of the discharge order. Michelle asked another logical question: “But do we know what is wrong with her yet? Has the diarrhea stopped?” The nurse recounted “only a few bowel movements” over the course of the night and no vomiting. Michelle pleaded with the nurse to at least see if her mom could tolerate breakfast before discharge. She then talked to the hospitalist, who recounted that Sheila had told him that morning that she had not had any diarrhea all night. Michelle asked another logical question, “But you know she has Alzheimer’s, right?”
Sheila did well with breakfast, and, after several hours without diarrhea, she was discharged back to her assisted living facility with Michelle. The PCP never called, home health was never ordered, and the low-cost medication was still on her discharge paperwork.
Bottom Line
Throughout all this, my sisters asked me and others so many logical questions during the three-week illness, such as “Don’t they review the medication list before a patient goes home?” and “Why didn’t the ED contact the PCP? He works in the same hospital, right?” Being hundreds of miles away, and knowing both how the system should work and how it does work, I found it sobering to see all the typical breakdowns happening to my own family. I felt disappointed and dismayed, but not the least bit surprised.
The one person who truly made a difference was the nurse at the assisted living facility, who used common sense (“The medication looks different”) and compassion (“Hi, just calling to check on Sheila”) to help us determine what was wrong. She saved us all additional diagnostic tests and unnecessary visits.
As a chief quality officer, I talk incessantly about systems approaches to improving quality and safety, but while I know how impactful reliable systems can be on good outcomes, the system will only ever be as good as the people caring within.
The experience I describe here is an acute illness that my family experienced. Aside from the actual illness, most of the story will not sound surprising or unique to most of you. It is a story about traversing the medical system to get care for my mom, an elderly patient with Alzheimer’s, over the course of three weeks. It is a story about miscommunications and fumbled handoffs, and complex insurance and payments systems that drive decision-making.
In this column, I aim only to describe our experience, which was both predictable and disappointing, within the healthcare system that we all own.
The Background
Sheila is a 76-year-old Caucasian female with a history of well-controlled hypertension and hyperlipidemia and moderate-stage Alzheimer’s disease, diagnosed about six years ago. She has resided in an assisted living facility for about three years and is still relatively independent in her activities of daily living (ADLs). She has remained relatively healthy and active despite her continuously progressive Alzheimer’s.
Her acute illness started when she developed diarrhea that was moderate in volume and frequency. Over the course of several days, the diarrhea significantly affected her sleep and activities, and she became more confused and essentially confined to her room. By day five, she was visibly dehydrated, with dry, cracked lips and skin tenting. Her daughter, Tara, brought her to the ED in the hospital at which her PCP was on staff. During the eight-hour ED stay, Sheila was rehydrated and was able to keep oral fluids down. Her blood work was normal, although the staff were unable to collect a stool sample. Sheila was discharged with instructions to see her PCP within a few days. No one from the ED contacted the PCP, and no one was able to set up a follow-up appointment.
The next day the diarrhea continued, so Tara contacted the PCP. The office staff noted that their next available appointment was in five days. Tara took that appointment and continued to help her mom with symptom management. Over the next several days, the diarrhea continued and the dehydration worsened again, so Tara took her back to the same ED, where they reassured her that the labs were normal, sent a stool sample off for testing, rehydrated her, and sent her home again. On the discharge paperwork, the ED physician noted that they had “set up home health nursing” and instructed a follow-up with Sheila’s PCP.
The next day, Tara contacted the PCP to check on the upcoming appointment, get advice on what to do, and see when the home health nurse would arrive. The PCP office confirmed the upcoming appointment in two days, told her to continue what she was doing, and said they did not know anything of the home health order and that she should contact the ED to clarify. When she contacted the ED, staff there told her the PCP would have to order the home health; Tara then called the PCP again, and he said he could not order home health, given the fact that he had not yet seen Sheila or her ED record. Tara asked a logical question, “But don’t you have the ED records? That is your hospital, right?”
The same cycle ensued over the next few days—now two weeks into the illness—and Sheila started to require increasing assistance with all of her ADLs, including toileting and showering, along with constant supervision to ensure hydration. The family pieced together as much help as possible. Several days later, on a Thursday night, the dehydration was again obvious, so Tara took her to another ED, given the lack of assistance received from the first two ED visits. In this ED, after evaluation, they admitted Sheila for observation. The family again pieced together 24/7 coverage for the hospital stay. The next day, Sheila continued to have diarrhea, now with vomiting. The ED hydrated her and relieved her vomiting and diarrhea with medications.
Because she was in observation, the hospitalist informed the family that he had written a discharge order. The family requested more time, given the fact that she was extremely confused, was hallucinating, and had not kept anything down by mouth; the hospitalist then changed Sheila to inpatient status for ongoing care. By Saturday, the vomiting and diarrhea were much better controlled with medications, but she had not taken anything by mouth other than a few sips of liquid. She was given a regular diet and kept a few bites down. The rounding hospitalist (the third in three days) told Tara he had consulted gastroenterology but that they were no longer needed and Sheila could be discharged. Tara requested that they fulfill the GI consult instead of discharging Sheila, given the length of time of the illness (now almost three weeks), the fact that she was nowhere near her baseline status, and the lack of diagnosis.
In the meantime, when one of the nurses from the assisted living facility called Tara to check on Sheila, she pointed out that she had noticed her mother’s Alzheimer’s medication “looked different” starting about three weeks ago, which coincided with the onset of the diarrhea. With this information, the GI consultant took a good history, looked at the imaging and lab testing, and told the family he strongly suspected the diarrhea had been caused by a change to generic from brand name, a decision that had been made due to the cost of brand name. He recommended stopping the medication, and, if no improvement was seen in the diarrhea within 48 hours, he would expand his workup.
The next day, a Sunday, the same hospitalist rounded early and wrote discharge orders. When Tara’s sister, Michelle, arrived, the nurse told her of the discharge order. Michelle asked another logical question: “But do we know what is wrong with her yet? Has the diarrhea stopped?” The nurse recounted “only a few bowel movements” over the course of the night and no vomiting. Michelle pleaded with the nurse to at least see if her mom could tolerate breakfast before discharge. She then talked to the hospitalist, who recounted that Sheila had told him that morning that she had not had any diarrhea all night. Michelle asked another logical question, “But you know she has Alzheimer’s, right?”
Sheila did well with breakfast, and, after several hours without diarrhea, she was discharged back to her assisted living facility with Michelle. The PCP never called, home health was never ordered, and the low-cost medication was still on her discharge paperwork.
Bottom Line
Throughout all this, my sisters asked me and others so many logical questions during the three-week illness, such as “Don’t they review the medication list before a patient goes home?” and “Why didn’t the ED contact the PCP? He works in the same hospital, right?” Being hundreds of miles away, and knowing both how the system should work and how it does work, I found it sobering to see all the typical breakdowns happening to my own family. I felt disappointed and dismayed, but not the least bit surprised.
The one person who truly made a difference was the nurse at the assisted living facility, who used common sense (“The medication looks different”) and compassion (“Hi, just calling to check on Sheila”) to help us determine what was wrong. She saved us all additional diagnostic tests and unnecessary visits.
As a chief quality officer, I talk incessantly about systems approaches to improving quality and safety, but while I know how impactful reliable systems can be on good outcomes, the system will only ever be as good as the people caring within.
The experience I describe here is an acute illness that my family experienced. Aside from the actual illness, most of the story will not sound surprising or unique to most of you. It is a story about traversing the medical system to get care for my mom, an elderly patient with Alzheimer’s, over the course of three weeks. It is a story about miscommunications and fumbled handoffs, and complex insurance and payments systems that drive decision-making.
In this column, I aim only to describe our experience, which was both predictable and disappointing, within the healthcare system that we all own.
The Background
Sheila is a 76-year-old Caucasian female with a history of well-controlled hypertension and hyperlipidemia and moderate-stage Alzheimer’s disease, diagnosed about six years ago. She has resided in an assisted living facility for about three years and is still relatively independent in her activities of daily living (ADLs). She has remained relatively healthy and active despite her continuously progressive Alzheimer’s.
Her acute illness started when she developed diarrhea that was moderate in volume and frequency. Over the course of several days, the diarrhea significantly affected her sleep and activities, and she became more confused and essentially confined to her room. By day five, she was visibly dehydrated, with dry, cracked lips and skin tenting. Her daughter, Tara, brought her to the ED in the hospital at which her PCP was on staff. During the eight-hour ED stay, Sheila was rehydrated and was able to keep oral fluids down. Her blood work was normal, although the staff were unable to collect a stool sample. Sheila was discharged with instructions to see her PCP within a few days. No one from the ED contacted the PCP, and no one was able to set up a follow-up appointment.
The next day the diarrhea continued, so Tara contacted the PCP. The office staff noted that their next available appointment was in five days. Tara took that appointment and continued to help her mom with symptom management. Over the next several days, the diarrhea continued and the dehydration worsened again, so Tara took her back to the same ED, where they reassured her that the labs were normal, sent a stool sample off for testing, rehydrated her, and sent her home again. On the discharge paperwork, the ED physician noted that they had “set up home health nursing” and instructed a follow-up with Sheila’s PCP.
The next day, Tara contacted the PCP to check on the upcoming appointment, get advice on what to do, and see when the home health nurse would arrive. The PCP office confirmed the upcoming appointment in two days, told her to continue what she was doing, and said they did not know anything of the home health order and that she should contact the ED to clarify. When she contacted the ED, staff there told her the PCP would have to order the home health; Tara then called the PCP again, and he said he could not order home health, given the fact that he had not yet seen Sheila or her ED record. Tara asked a logical question, “But don’t you have the ED records? That is your hospital, right?”
The same cycle ensued over the next few days—now two weeks into the illness—and Sheila started to require increasing assistance with all of her ADLs, including toileting and showering, along with constant supervision to ensure hydration. The family pieced together as much help as possible. Several days later, on a Thursday night, the dehydration was again obvious, so Tara took her to another ED, given the lack of assistance received from the first two ED visits. In this ED, after evaluation, they admitted Sheila for observation. The family again pieced together 24/7 coverage for the hospital stay. The next day, Sheila continued to have diarrhea, now with vomiting. The ED hydrated her and relieved her vomiting and diarrhea with medications.
Because she was in observation, the hospitalist informed the family that he had written a discharge order. The family requested more time, given the fact that she was extremely confused, was hallucinating, and had not kept anything down by mouth; the hospitalist then changed Sheila to inpatient status for ongoing care. By Saturday, the vomiting and diarrhea were much better controlled with medications, but she had not taken anything by mouth other than a few sips of liquid. She was given a regular diet and kept a few bites down. The rounding hospitalist (the third in three days) told Tara he had consulted gastroenterology but that they were no longer needed and Sheila could be discharged. Tara requested that they fulfill the GI consult instead of discharging Sheila, given the length of time of the illness (now almost three weeks), the fact that she was nowhere near her baseline status, and the lack of diagnosis.
In the meantime, when one of the nurses from the assisted living facility called Tara to check on Sheila, she pointed out that she had noticed her mother’s Alzheimer’s medication “looked different” starting about three weeks ago, which coincided with the onset of the diarrhea. With this information, the GI consultant took a good history, looked at the imaging and lab testing, and told the family he strongly suspected the diarrhea had been caused by a change to generic from brand name, a decision that had been made due to the cost of brand name. He recommended stopping the medication, and, if no improvement was seen in the diarrhea within 48 hours, he would expand his workup.
The next day, a Sunday, the same hospitalist rounded early and wrote discharge orders. When Tara’s sister, Michelle, arrived, the nurse told her of the discharge order. Michelle asked another logical question: “But do we know what is wrong with her yet? Has the diarrhea stopped?” The nurse recounted “only a few bowel movements” over the course of the night and no vomiting. Michelle pleaded with the nurse to at least see if her mom could tolerate breakfast before discharge. She then talked to the hospitalist, who recounted that Sheila had told him that morning that she had not had any diarrhea all night. Michelle asked another logical question, “But you know she has Alzheimer’s, right?”
Sheila did well with breakfast, and, after several hours without diarrhea, she was discharged back to her assisted living facility with Michelle. The PCP never called, home health was never ordered, and the low-cost medication was still on her discharge paperwork.
Bottom Line
Throughout all this, my sisters asked me and others so many logical questions during the three-week illness, such as “Don’t they review the medication list before a patient goes home?” and “Why didn’t the ED contact the PCP? He works in the same hospital, right?” Being hundreds of miles away, and knowing both how the system should work and how it does work, I found it sobering to see all the typical breakdowns happening to my own family. I felt disappointed and dismayed, but not the least bit surprised.
The one person who truly made a difference was the nurse at the assisted living facility, who used common sense (“The medication looks different”) and compassion (“Hi, just calling to check on Sheila”) to help us determine what was wrong. She saved us all additional diagnostic tests and unnecessary visits.
As a chief quality officer, I talk incessantly about systems approaches to improving quality and safety, but while I know how impactful reliable systems can be on good outcomes, the system will only ever be as good as the people caring within.
Why It's Hard for Healthcare Providers to Say I'm Sorry
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