Stephanie Cajigal

Katherine Dallow, MD, is attending HM09 to interact with colleagues, take a variety of CME courses, and to prepare for American Board of Internal Medicine (ABIM) board certification.

"I already feel smarter," says Dr. Dallow, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Dr. Dallow, one of more than 2,000 hospitalists attending the annual meeting, says she enjoys how SHM condenses all of its events into four days. "There is not a single period of time when there isn't a lecture you want to go to," she says.

In fact, HM09's course offerings are what motivated Gonzalo Eymin, MD, to travel to Chicago from his hometown of Santiago, Chile. Dr. Eymin, one of six internists at Clinical Hospital of the Catholic University of Chile who work primarily with inpatients, says he wants to learn how the HM model works in the U.S. The term "hospitalist" doesn't exist in Chile, he says.

"It's changing in the medical environment, but the economic people, the people who handle the money, [are who] we have to convince," he says.

Even though he's been a practicing hospitalist since 1993, J. Kevin Shustari, MD, FHM, is as confused as ever about reimbursement issues. That's why he's focusing on HM09's coding and billing sessions.

"There are things that are still nebulous," says Dr. Shustari, director of Hospital Internists of New London, an HM group based in Farmington, Conn. "One of the things that’s really gratifying to see is that everybody is struggling with the same issues across the country on a national level: billing, how to conduct a practice effectively, scheduling. We’re still an evolving specialty, so we’re all still learning."

Katherine Dallow, MD, is attending HM09 to interact with colleagues, take a variety of CME courses, and to prepare for American Board of Internal Medicine (ABIM) board certification.

"I already feel smarter," says Dr. Dallow, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Dr. Dallow, one of more than 2,000 hospitalists attending the annual meeting, says she enjoys how SHM condenses all of its events into four days. "There is not a single period of time when there isn't a lecture you want to go to," she says.

In fact, HM09's course offerings are what motivated Gonzalo Eymin, MD, to travel to Chicago from his hometown of Santiago, Chile. Dr. Eymin, one of six internists at Clinical Hospital of the Catholic University of Chile who work primarily with inpatients, says he wants to learn how the HM model works in the U.S. The term "hospitalist" doesn't exist in Chile, he says.

"It's changing in the medical environment, but the economic people, the people who handle the money, [are who] we have to convince," he says.

Even though he's been a practicing hospitalist since 1993, J. Kevin Shustari, MD, FHM, is as confused as ever about reimbursement issues. That's why he's focusing on HM09's coding and billing sessions.

"There are things that are still nebulous," says Dr. Shustari, director of Hospital Internists of New London, an HM group based in Farmington, Conn. "One of the things that’s really gratifying to see is that everybody is struggling with the same issues across the country on a national level: billing, how to conduct a practice effectively, scheduling. We’re still an evolving specialty, so we’re all still learning."

Katherine Dallow, MD, is attending HM09 to interact with colleagues, take a variety of CME courses, and to prepare for American Board of Internal Medicine (ABIM) board certification.

"I already feel smarter," says Dr. Dallow, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Dr. Dallow, one of more than 2,000 hospitalists attending the annual meeting, says she enjoys how SHM condenses all of its events into four days. "There is not a single period of time when there isn't a lecture you want to go to," she says.

In fact, HM09's course offerings are what motivated Gonzalo Eymin, MD, to travel to Chicago from his hometown of Santiago, Chile. Dr. Eymin, one of six internists at Clinical Hospital of the Catholic University of Chile who work primarily with inpatients, says he wants to learn how the HM model works in the U.S. The term "hospitalist" doesn't exist in Chile, he says.

"It's changing in the medical environment, but the economic people, the people who handle the money, [are who] we have to convince," he says.

Even though he's been a practicing hospitalist since 1993, J. Kevin Shustari, MD, FHM, is as confused as ever about reimbursement issues. That's why he's focusing on HM09's coding and billing sessions.

"There are things that are still nebulous," says Dr. Shustari, director of Hospital Internists of New London, an HM group based in Farmington, Conn. "One of the things that’s really gratifying to see is that everybody is struggling with the same issues across the country on a national level: billing, how to conduct a practice effectively, scheduling. We’re still an evolving specialty, so we’re all still learning."

With all the healthcare policy changes President Obama is hoping to usher in over the next few years, it might be comforting to know that a hospitalist will be leading at least one of these initiatives. Patrick Conway, MD, has been selected to serve as executive director of the Department of Health and Human Services’ (HHS) Federal Coordinating Council for Comparative Effectiveness Research. Authorized by the American Recovery and Reinvestment Act, the council is responsible for allocating $1.1 billion for research that will compare various medical interventions.

Dr. Conway, a pediatric hospitalist who also is chief medical officer in the policy division of the Office of Secretary at HHS and does weekend rounds at Children’s National Medical Center in Washington, D.C., spoke with the TH eWire about his new role.

Some physicians are concerned the Centers for Medicare & Medicaid Services (CMS) will use the council’s findings to make payment decisions. Is this a valid worry?

They specifically put in the Recovery Act that this information should not be construed as mandates or clinical guidelines for coverage or payment. Our purview now is to fund the research that provides the information.

Is there a lack of comparative effectiveness research?

Yes. The reason this is important is there are so many common clinical decisions that as a clinician or patient we don’t know the answer to. I’ll give you one concrete example from last week when I was on service. A mother’s child who is neurologically impaired and therefore [has gastroesophageal reflux disease] asked me if [her child] should have surgery or medical management for this problem. So I have to have the painful conversation with her that there’s not good evidence to inform or start to point to whether for her child or the specific circumstances of her child she should get surgery or medical treatment.

How can get hospitalists get involved in this project?

Hospitalists should try to be on the agenda for public listening sessions to share their viewpoints. There will be spots for people to publicly read their testimony. There’ll also likely be the ability to submit comments online.

For more information or to sign up for the council’s Listening Sessions, visit www.hhs.gov/recovery/programs/cer/index.html.

With all the healthcare policy changes President Obama is hoping to usher in over the next few years, it might be comforting to know that a hospitalist will be leading at least one of these initiatives. Patrick Conway, MD, has been selected to serve as executive director of the Department of Health and Human Services’ (HHS) Federal Coordinating Council for Comparative Effectiveness Research. Authorized by the American Recovery and Reinvestment Act, the council is responsible for allocating $1.1 billion for research that will compare various medical interventions.

Dr. Conway, a pediatric hospitalist who also is chief medical officer in the policy division of the Office of Secretary at HHS and does weekend rounds at Children’s National Medical Center in Washington, D.C., spoke with the TH eWire about his new role.

Some physicians are concerned the Centers for Medicare & Medicaid Services (CMS) will use the council’s findings to make payment decisions. Is this a valid worry?

They specifically put in the Recovery Act that this information should not be construed as mandates or clinical guidelines for coverage or payment. Our purview now is to fund the research that provides the information.

Is there a lack of comparative effectiveness research?

Yes. The reason this is important is there are so many common clinical decisions that as a clinician or patient we don’t know the answer to. I’ll give you one concrete example from last week when I was on service. A mother’s child who is neurologically impaired and therefore [has gastroesophageal reflux disease] asked me if [her child] should have surgery or medical management for this problem. So I have to have the painful conversation with her that there’s not good evidence to inform or start to point to whether for her child or the specific circumstances of her child she should get surgery or medical treatment.

How can get hospitalists get involved in this project?

Hospitalists should try to be on the agenda for public listening sessions to share their viewpoints. There will be spots for people to publicly read their testimony. There’ll also likely be the ability to submit comments online.

For more information or to sign up for the council’s Listening Sessions, visit www.hhs.gov/recovery/programs/cer/index.html.

With all the healthcare policy changes President Obama is hoping to usher in over the next few years, it might be comforting to know that a hospitalist will be leading at least one of these initiatives. Patrick Conway, MD, has been selected to serve as executive director of the Department of Health and Human Services’ (HHS) Federal Coordinating Council for Comparative Effectiveness Research. Authorized by the American Recovery and Reinvestment Act, the council is responsible for allocating $1.1 billion for research that will compare various medical interventions.

Dr. Conway, a pediatric hospitalist who also is chief medical officer in the policy division of the Office of Secretary at HHS and does weekend rounds at Children’s National Medical Center in Washington, D.C., spoke with the TH eWire about his new role.

Some physicians are concerned the Centers for Medicare & Medicaid Services (CMS) will use the council’s findings to make payment decisions. Is this a valid worry?

They specifically put in the Recovery Act that this information should not be construed as mandates or clinical guidelines for coverage or payment. Our purview now is to fund the research that provides the information.

Is there a lack of comparative effectiveness research?

Yes. The reason this is important is there are so many common clinical decisions that as a clinician or patient we don’t know the answer to. I’ll give you one concrete example from last week when I was on service. A mother’s child who is neurologically impaired and therefore [has gastroesophageal reflux disease] asked me if [her child] should have surgery or medical management for this problem. So I have to have the painful conversation with her that there’s not good evidence to inform or start to point to whether for her child or the specific circumstances of her child she should get surgery or medical treatment.

How can get hospitalists get involved in this project?

Hospitalists should try to be on the agenda for public listening sessions to share their viewpoints. There will be spots for people to publicly read their testimony. There’ll also likely be the ability to submit comments online.

For more information or to sign up for the council’s Listening Sessions, visit www.hhs.gov/recovery/programs/cer/index.html.

Now that more swine flu cases have been reported in New York City than in any other part of the U.S., local hospitalists are preparing to handle a potential influx of ill patients.

Dahlia Rizk, DO, FHM, director of the hospitalist program at Beth Israel Medical Center (BIMC) in New York City, says her 20-member team is receiving daily briefings from the hospital’s infection control expert. Hospitalists are learning about the latest confirmed cases and guidelines from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the NYC Department of Health and Mental Hygiene. Dr. Rizk is sharing the information with the rest of the hospital staff.

"This is our home; this is where we spend 90% of our day, if not 100%," Dr. Rizk says. “The staff know us, they rely on us, recognize us, and expect information and help from us when it comes to these kinds of situations."

John Novotny, MD, associate director of the hospitalist program at BIMC, says the hospital's strategy focuses on containing the virus and protecting other patients and staff from becoming infected by placing suspected swine flu patients in an isolation room that prevents the illness from being transmitted through droplets in the air. In addition, staff members will be expected to wear an N95 respirator facemask when entering the rooms of swine flu patients. Patients who are placed in the isolation room will be administered a PCR nasal swab test to confirm whether they are infected with influenza.

Dr. Rizk says patients showing mild to moderate symptoms will be asked to go home and remain there for seven days to reduce the chances of infecting others. “During this emergency, it is especially important to limit admissions of suspected influenza to those patients with more serious clinical conditions or significant comorbidities," she explains. "We need to focus on the priority of avoiding exposing other vulnerable inpatients to influenza, such as the elderly, the immune-compromised, or those with chronic heart and lung conditions.”

Drs. Novotny and Rizk suggest hospitalists follow these swine flu preparation tips:

• Communicate. Keep nurses and other staff up to date about the latest treatment and containment guidelines.
• Establish expectations. Be aware that staffers are looking to hospitalists for guidance during this emergency situation.
• Monitor for updates. Stay informed through your infectious disease division, the CDC, the WHO, and your local public health department.

For more information, visit the CDC website.

Now that more swine flu cases have been reported in New York City than in any other part of the U.S., local hospitalists are preparing to handle a potential influx of ill patients.

Dahlia Rizk, DO, FHM, director of the hospitalist program at Beth Israel Medical Center (BIMC) in New York City, says her 20-member team is receiving daily briefings from the hospital’s infection control expert. Hospitalists are learning about the latest confirmed cases and guidelines from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the NYC Department of Health and Mental Hygiene. Dr. Rizk is sharing the information with the rest of the hospital staff.

"This is our home; this is where we spend 90% of our day, if not 100%," Dr. Rizk says. “The staff know us, they rely on us, recognize us, and expect information and help from us when it comes to these kinds of situations."

John Novotny, MD, associate director of the hospitalist program at BIMC, says the hospital's strategy focuses on containing the virus and protecting other patients and staff from becoming infected by placing suspected swine flu patients in an isolation room that prevents the illness from being transmitted through droplets in the air. In addition, staff members will be expected to wear an N95 respirator facemask when entering the rooms of swine flu patients. Patients who are placed in the isolation room will be administered a PCR nasal swab test to confirm whether they are infected with influenza.

Dr. Rizk says patients showing mild to moderate symptoms will be asked to go home and remain there for seven days to reduce the chances of infecting others. “During this emergency, it is especially important to limit admissions of suspected influenza to those patients with more serious clinical conditions or significant comorbidities," she explains. "We need to focus on the priority of avoiding exposing other vulnerable inpatients to influenza, such as the elderly, the immune-compromised, or those with chronic heart and lung conditions.”

Drs. Novotny and Rizk suggest hospitalists follow these swine flu preparation tips:

• Communicate. Keep nurses and other staff up to date about the latest treatment and containment guidelines.
• Establish expectations. Be aware that staffers are looking to hospitalists for guidance during this emergency situation.
• Monitor for updates. Stay informed through your infectious disease division, the CDC, the WHO, and your local public health department.

For more information, visit the CDC website.

Now that more swine flu cases have been reported in New York City than in any other part of the U.S., local hospitalists are preparing to handle a potential influx of ill patients.

Dahlia Rizk, DO, FHM, director of the hospitalist program at Beth Israel Medical Center (BIMC) in New York City, says her 20-member team is receiving daily briefings from the hospital’s infection control expert. Hospitalists are learning about the latest confirmed cases and guidelines from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the NYC Department of Health and Mental Hygiene. Dr. Rizk is sharing the information with the rest of the hospital staff.

"This is our home; this is where we spend 90% of our day, if not 100%," Dr. Rizk says. “The staff know us, they rely on us, recognize us, and expect information and help from us when it comes to these kinds of situations."

John Novotny, MD, associate director of the hospitalist program at BIMC, says the hospital's strategy focuses on containing the virus and protecting other patients and staff from becoming infected by placing suspected swine flu patients in an isolation room that prevents the illness from being transmitted through droplets in the air. In addition, staff members will be expected to wear an N95 respirator facemask when entering the rooms of swine flu patients. Patients who are placed in the isolation room will be administered a PCR nasal swab test to confirm whether they are infected with influenza.

Dr. Rizk says patients showing mild to moderate symptoms will be asked to go home and remain there for seven days to reduce the chances of infecting others. “During this emergency, it is especially important to limit admissions of suspected influenza to those patients with more serious clinical conditions or significant comorbidities," she explains. "We need to focus on the priority of avoiding exposing other vulnerable inpatients to influenza, such as the elderly, the immune-compromised, or those with chronic heart and lung conditions.”

Drs. Novotny and Rizk suggest hospitalists follow these swine flu preparation tips:

• Communicate. Keep nurses and other staff up to date about the latest treatment and containment guidelines.
• Establish expectations. Be aware that staffers are looking to hospitalists for guidance during this emergency situation.
• Monitor for updates. Stay informed through your infectious disease division, the CDC, the WHO, and your local public health department.

For more information, visit the CDC website.

You know that feeling of frustration you get when something that should work—computers, airline schedules—just doesn't? Here's something new to add to that list: prostate cancer screenings.

Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California at San Francisco and author of Wachter’s World, sums up the findings of two recent New England Journal of Medicine studies in a recent post.

“One, a European study, found that PSA screening led to little benefit. The American study found that, after seven years of followup, the unscreened group had a 13% lower mortality rate than the screened group, with not a whiff of benefit.”

Dr. Wachter describes how his own father chose not to act on a PSA that came back in the 8 ng/mL range in the late 1990s. His father recently turned 79 and is healthy. “A heartfelt thanks to my dad’s urologists, who gave him what proved to be sage advice when all of the pressures—social, psychological, and financial—might have steered them toward more aggressive recommendations,” Dr. Wachter writes.

A Smarter Investment?

The Happy Hospitalist ponders what would happen if the $8,760 a year his patient and her husband spent on cigarettes was invested in the stock market. “Let’s say that the price of a pack of cigarettes only rises 5% a year (a conservative estimate). How much money could you save up by not spending $8,760 on cigarettes and instead investing it with a post-inflation return on average of 7%?”

The answer? After 10 years, the total would be $153,716; after 50 years, it would be $5.8 million.

“My, how foolish we are as a nation,” The Happy Hospitalist writes. “Looking for ways to pay for the healthcare of its citizenry, when the answers are staring us in the face.”

Brave New Hospitalist

HM welcomes a rookie to the ranks this week. Spiffer, an internist from California who doesn’t mince words on her blog, explains her new gig as a hospitalist to patients. “This is the doctor that will come and ask you about 700 annoying questions while you lay, uncomfortably, in the overcrowded emergency room. And this person will, ideally, follow you for much, if not all, of your stay in the hospital.

“I love my patients and will miss them,” she says. “But here I go, into a brave new world.”

Welcome, Spiffer. 

You know that feeling of frustration you get when something that should work—computers, airline schedules—just doesn't? Here's something new to add to that list: prostate cancer screenings.

Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California at San Francisco and author of Wachter’s World, sums up the findings of two recent New England Journal of Medicine studies in a recent post.

“One, a European study, found that PSA screening led to little benefit. The American study found that, after seven years of followup, the unscreened group had a 13% lower mortality rate than the screened group, with not a whiff of benefit.”

Dr. Wachter describes how his own father chose not to act on a PSA that came back in the 8 ng/mL range in the late 1990s. His father recently turned 79 and is healthy. “A heartfelt thanks to my dad’s urologists, who gave him what proved to be sage advice when all of the pressures—social, psychological, and financial—might have steered them toward more aggressive recommendations,” Dr. Wachter writes.

A Smarter Investment?

The Happy Hospitalist ponders what would happen if the $8,760 a year his patient and her husband spent on cigarettes was invested in the stock market. “Let’s say that the price of a pack of cigarettes only rises 5% a year (a conservative estimate). How much money could you save up by not spending $8,760 on cigarettes and instead investing it with a post-inflation return on average of 7%?”

The answer? After 10 years, the total would be $153,716; after 50 years, it would be $5.8 million.

“My, how foolish we are as a nation,” The Happy Hospitalist writes. “Looking for ways to pay for the healthcare of its citizenry, when the answers are staring us in the face.”

Brave New Hospitalist

HM welcomes a rookie to the ranks this week. Spiffer, an internist from California who doesn’t mince words on her blog, explains her new gig as a hospitalist to patients. “This is the doctor that will come and ask you about 700 annoying questions while you lay, uncomfortably, in the overcrowded emergency room. And this person will, ideally, follow you for much, if not all, of your stay in the hospital.

“I love my patients and will miss them,” she says. “But here I go, into a brave new world.”

Welcome, Spiffer. 

You know that feeling of frustration you get when something that should work—computers, airline schedules—just doesn't? Here's something new to add to that list: prostate cancer screenings.

Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California at San Francisco and author of Wachter’s World, sums up the findings of two recent New England Journal of Medicine studies in a recent post.

“One, a European study, found that PSA screening led to little benefit. The American study found that, after seven years of followup, the unscreened group had a 13% lower mortality rate than the screened group, with not a whiff of benefit.”

Dr. Wachter describes how his own father chose not to act on a PSA that came back in the 8 ng/mL range in the late 1990s. His father recently turned 79 and is healthy. “A heartfelt thanks to my dad’s urologists, who gave him what proved to be sage advice when all of the pressures—social, psychological, and financial—might have steered them toward more aggressive recommendations,” Dr. Wachter writes.

A Smarter Investment?

The Happy Hospitalist ponders what would happen if the $8,760 a year his patient and her husband spent on cigarettes was invested in the stock market. “Let’s say that the price of a pack of cigarettes only rises 5% a year (a conservative estimate). How much money could you save up by not spending $8,760 on cigarettes and instead investing it with a post-inflation return on average of 7%?”

The answer? After 10 years, the total would be $153,716; after 50 years, it would be $5.8 million.

“My, how foolish we are as a nation,” The Happy Hospitalist writes. “Looking for ways to pay for the healthcare of its citizenry, when the answers are staring us in the face.”

Brave New Hospitalist

HM welcomes a rookie to the ranks this week. Spiffer, an internist from California who doesn’t mince words on her blog, explains her new gig as a hospitalist to patients. “This is the doctor that will come and ask you about 700 annoying questions while you lay, uncomfortably, in the overcrowded emergency room. And this person will, ideally, follow you for much, if not all, of your stay in the hospital.

“I love my patients and will miss them,” she says. “But here I go, into a brave new world.”

Welcome, Spiffer. 

It seems appropriate that in the same month President Obama signed a $787 billion economic stimulus package, the preferred topic of choice in the blogosphere would focus on money—or, more specifically, lack of it.

On his blog "Dr. Wes," Westby G. Fisher, MD, an internist, cardiologist, and cardiac electrophysiologist, warns about the looming Medicare physician fee cuts that Congress might not prevent this year as pressure increases to trim healthcare costs. Physicians should plan to work with the American Medical Association (AMA) to prevent the cuts, he writes.

"Do we honestly think that our individual subspecialty societies for cardiologists, internists, surgeons, hospitalists, or even newer, heavily promoted doctors' Internet sites will hold a policy-making candle to the AMA's lobbying stature on the Hill? No way."

Agree or disagree? Post your comment.

Speaking of healthcare spending, The Wall Street Journal Health Blog writer Jacob Goldstein reports startling figures recently published in Health Affairs: a 5.5% projected rise in U.S. healthcare spending this year and healthcare projecting to make up 17.6% of total GDP, compared with 16.6% last year.

Commenting on Goldstein’s post, urologist James G. Knight, MD, CEO of Consumer Directed Health Care Inc., had the following to say: "While everyone should have major medical insurance that protects them from financial ruin, each person should be financially responsible for their day-to-day care. This gives people who smoke, are overweight, or who have other behavior-related illnesses a financial incentive to manage their personal health."

FridaWrites of Hospitalist With a View offers another option to lower health spending: "Jumbo serving sizes are the enemy—in our house, half a bagel is enough and we split restaurant orders and enjoy leftovers; this also makes eating out on occasion more affordable. In some coffee shops, we've seen that one muffin or cookie in the display is large enough to serve a whole family. Teaching people to measure portions and count calories seems to be important—and this goes for hospital meals, too, where I've also seen surprisingly large portion sizes for people who don't need to gain weight."

It seems appropriate that in the same month President Obama signed a $787 billion economic stimulus package, the preferred topic of choice in the blogosphere would focus on money—or, more specifically, lack of it.

On his blog "Dr. Wes," Westby G. Fisher, MD, an internist, cardiologist, and cardiac electrophysiologist, warns about the looming Medicare physician fee cuts that Congress might not prevent this year as pressure increases to trim healthcare costs. Physicians should plan to work with the American Medical Association (AMA) to prevent the cuts, he writes.

"Do we honestly think that our individual subspecialty societies for cardiologists, internists, surgeons, hospitalists, or even newer, heavily promoted doctors' Internet sites will hold a policy-making candle to the AMA's lobbying stature on the Hill? No way."

Agree or disagree? Post your comment.

Speaking of healthcare spending, The Wall Street Journal Health Blog writer Jacob Goldstein reports startling figures recently published in Health Affairs: a 5.5% projected rise in U.S. healthcare spending this year and healthcare projecting to make up 17.6% of total GDP, compared with 16.6% last year.

Commenting on Goldstein’s post, urologist James G. Knight, MD, CEO of Consumer Directed Health Care Inc., had the following to say: "While everyone should have major medical insurance that protects them from financial ruin, each person should be financially responsible for their day-to-day care. This gives people who smoke, are overweight, or who have other behavior-related illnesses a financial incentive to manage their personal health."

FridaWrites of Hospitalist With a View offers another option to lower health spending: "Jumbo serving sizes are the enemy—in our house, half a bagel is enough and we split restaurant orders and enjoy leftovers; this also makes eating out on occasion more affordable. In some coffee shops, we've seen that one muffin or cookie in the display is large enough to serve a whole family. Teaching people to measure portions and count calories seems to be important—and this goes for hospital meals, too, where I've also seen surprisingly large portion sizes for people who don't need to gain weight."

It seems appropriate that in the same month President Obama signed a $787 billion economic stimulus package, the preferred topic of choice in the blogosphere would focus on money—or, more specifically, lack of it.

On his blog "Dr. Wes," Westby G. Fisher, MD, an internist, cardiologist, and cardiac electrophysiologist, warns about the looming Medicare physician fee cuts that Congress might not prevent this year as pressure increases to trim healthcare costs. Physicians should plan to work with the American Medical Association (AMA) to prevent the cuts, he writes.

"Do we honestly think that our individual subspecialty societies for cardiologists, internists, surgeons, hospitalists, or even newer, heavily promoted doctors' Internet sites will hold a policy-making candle to the AMA's lobbying stature on the Hill? No way."

Agree or disagree? Post your comment.

Speaking of healthcare spending, The Wall Street Journal Health Blog writer Jacob Goldstein reports startling figures recently published in Health Affairs: a 5.5% projected rise in U.S. healthcare spending this year and healthcare projecting to make up 17.6% of total GDP, compared with 16.6% last year.

Commenting on Goldstein’s post, urologist James G. Knight, MD, CEO of Consumer Directed Health Care Inc., had the following to say: "While everyone should have major medical insurance that protects them from financial ruin, each person should be financially responsible for their day-to-day care. This gives people who smoke, are overweight, or who have other behavior-related illnesses a financial incentive to manage their personal health."

FridaWrites of Hospitalist With a View offers another option to lower health spending: "Jumbo serving sizes are the enemy—in our house, half a bagel is enough and we split restaurant orders and enjoy leftovers; this also makes eating out on occasion more affordable. In some coffee shops, we've seen that one muffin or cookie in the display is large enough to serve a whole family. Teaching people to measure portions and count calories seems to be important—and this goes for hospital meals, too, where I've also seen surprisingly large portion sizes for people who don't need to gain weight."

Too busy rounding on patients to keep up with the blogosphere? We're doing the surfing for you in this first monthly roundup of what your colleagues are buzzing about in cyberspace.

First up: The Happy Hospitalist, who was not happy about Medco CEO Dave Snow's support of treatment protocols, had the following to say last week: "This guy doesn't get it. Cookbook medicine is but a tiny fraction of care. Perhaps 5% or less. I can admit a hemorrhagic stroke, follow standardized protocols, and the next 10 patients will have 10 different permutations of care. I can follow the guidelines to a T and every single patient's comorbid conditions will add layers upon layers of complication to the management."

On SHM's Hospitalist Leader blog, former SHM CEO Rusty Holman touched upon another frustration in the workplace: New hires who complain that "this isn't what I signed up for." Dr. Holman’s advice? When hiring explain that "the job you take today is likely— no, is certain— to be different a year from now." Dr. Holman assures practice managers that "as a leader, you will never be faulted for telling the truth."

Speaking of leaders, Health Beat's Maggie Mahar offered her thoughts on President Obama's inauguration speech: "When President Obama said, 'The time has come to put away childish things,' I couldn't help but recall healthcare reformer Don Berwick, sounding discouraged last winter, as he said, 'Maybe this country just isn't mature enough for healthcare reform.' Berwick, who is the president of the Institute for Healthcare Improvement, was referring to the fact that at times, it seems that everyone wants healthcare for all— but no one wants to pay for it."

Too busy rounding on patients to keep up with the blogosphere? We're doing the surfing for you in this first monthly roundup of what your colleagues are buzzing about in cyberspace.

First up: The Happy Hospitalist, who was not happy about Medco CEO Dave Snow's support of treatment protocols, had the following to say last week: "This guy doesn't get it. Cookbook medicine is but a tiny fraction of care. Perhaps 5% or less. I can admit a hemorrhagic stroke, follow standardized protocols, and the next 10 patients will have 10 different permutations of care. I can follow the guidelines to a T and every single patient's comorbid conditions will add layers upon layers of complication to the management."

On SHM's Hospitalist Leader blog, former SHM CEO Rusty Holman touched upon another frustration in the workplace: New hires who complain that "this isn't what I signed up for." Dr. Holman’s advice? When hiring explain that "the job you take today is likely— no, is certain— to be different a year from now." Dr. Holman assures practice managers that "as a leader, you will never be faulted for telling the truth."

Speaking of leaders, Health Beat's Maggie Mahar offered her thoughts on President Obama's inauguration speech: "When President Obama said, 'The time has come to put away childish things,' I couldn't help but recall healthcare reformer Don Berwick, sounding discouraged last winter, as he said, 'Maybe this country just isn't mature enough for healthcare reform.' Berwick, who is the president of the Institute for Healthcare Improvement, was referring to the fact that at times, it seems that everyone wants healthcare for all— but no one wants to pay for it."

Too busy rounding on patients to keep up with the blogosphere? We're doing the surfing for you in this first monthly roundup of what your colleagues are buzzing about in cyberspace.

First up: The Happy Hospitalist, who was not happy about Medco CEO Dave Snow's support of treatment protocols, had the following to say last week: "This guy doesn't get it. Cookbook medicine is but a tiny fraction of care. Perhaps 5% or less. I can admit a hemorrhagic stroke, follow standardized protocols, and the next 10 patients will have 10 different permutations of care. I can follow the guidelines to a T and every single patient's comorbid conditions will add layers upon layers of complication to the management."

On SHM's Hospitalist Leader blog, former SHM CEO Rusty Holman touched upon another frustration in the workplace: New hires who complain that "this isn't what I signed up for." Dr. Holman’s advice? When hiring explain that "the job you take today is likely— no, is certain— to be different a year from now." Dr. Holman assures practice managers that "as a leader, you will never be faulted for telling the truth."

Speaking of leaders, Health Beat's Maggie Mahar offered her thoughts on President Obama's inauguration speech: "When President Obama said, 'The time has come to put away childish things,' I couldn't help but recall healthcare reformer Don Berwick, sounding discouraged last winter, as he said, 'Maybe this country just isn't mature enough for healthcare reform.' Berwick, who is the president of the Institute for Healthcare Improvement, was referring to the fact that at times, it seems that everyone wants healthcare for all— but no one wants to pay for it."

Garth King, MD, a hospitalist and medical director at Southwest General Medical Center in Lafayette, La., wasn’t surprised he was treating an inebriated 17-year-old who came to the hospital with his mother this past New Year's Eve. The intoxicated 14-year-old who came in shortly after, however, did throw him slightly off guard.

"We usually just send them to the emergency room, where they are monitored," Dr. King says. "It's a waste of resources to admit them."

Kenneth Patrick, MD, a hospitalist and ICU director at Chestnut Hill Hospital in Philadelphia, says alcohol-related conditions, including gastritis and pancreatitis, are the most common cases he sees on New Year's Eve and New Year's Day. The second-most common, he says, are fractures caused by slipping on ice or snow.

"New Year's Day is the busiest day of the year for inpatients," Dr. Patrick says.

National data on daily hospital visits don't exist, but Dr. King agrees with Dr. Patrick's assessment. He says the number of patients his group normally sees doubles between Christmas Eve and New Year’s Day. "In residency, I remember this would happen," he says. "It would seem like family members would bring in their family members, just because."

If you are one of the unfortunate members of your HM group scheduled to work next holiday season, Dr. Patrick offers a little advice: "Stay well-hydrated and get lots of rest, because you will be busy."

Garth King, MD, a hospitalist and medical director at Southwest General Medical Center in Lafayette, La., wasn’t surprised he was treating an inebriated 17-year-old who came to the hospital with his mother this past New Year's Eve. The intoxicated 14-year-old who came in shortly after, however, did throw him slightly off guard.

"We usually just send them to the emergency room, where they are monitored," Dr. King says. "It's a waste of resources to admit them."

Kenneth Patrick, MD, a hospitalist and ICU director at Chestnut Hill Hospital in Philadelphia, says alcohol-related conditions, including gastritis and pancreatitis, are the most common cases he sees on New Year's Eve and New Year's Day. The second-most common, he says, are fractures caused by slipping on ice or snow.

"New Year's Day is the busiest day of the year for inpatients," Dr. Patrick says.

National data on daily hospital visits don't exist, but Dr. King agrees with Dr. Patrick's assessment. He says the number of patients his group normally sees doubles between Christmas Eve and New Year’s Day. "In residency, I remember this would happen," he says. "It would seem like family members would bring in their family members, just because."

If you are one of the unfortunate members of your HM group scheduled to work next holiday season, Dr. Patrick offers a little advice: "Stay well-hydrated and get lots of rest, because you will be busy."

Garth King, MD, a hospitalist and medical director at Southwest General Medical Center in Lafayette, La., wasn’t surprised he was treating an inebriated 17-year-old who came to the hospital with his mother this past New Year's Eve. The intoxicated 14-year-old who came in shortly after, however, did throw him slightly off guard.

"We usually just send them to the emergency room, where they are monitored," Dr. King says. "It's a waste of resources to admit them."

Kenneth Patrick, MD, a hospitalist and ICU director at Chestnut Hill Hospital in Philadelphia, says alcohol-related conditions, including gastritis and pancreatitis, are the most common cases he sees on New Year's Eve and New Year's Day. The second-most common, he says, are fractures caused by slipping on ice or snow.

"New Year's Day is the busiest day of the year for inpatients," Dr. Patrick says.

National data on daily hospital visits don't exist, but Dr. King agrees with Dr. Patrick's assessment. He says the number of patients his group normally sees doubles between Christmas Eve and New Year’s Day. "In residency, I remember this would happen," he says. "It would seem like family members would bring in their family members, just because."

If you are one of the unfortunate members of your HM group scheduled to work next holiday season, Dr. Patrick offers a little advice: "Stay well-hydrated and get lots of rest, because you will be busy."

Think a big hospital is where it’s at? Not according to Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahanock Hospital, a 67-bed facility in rural Tappahannock, Va. The community is home to 2,172 residents and located about an hour east of Richmond, just up river from the Chesapeake Bay. Dr. Ferrance, a former chiropractor who has been practicing as a hospitalist at Riverside since 2002, recently spoke with The Hospitalist about why he enjoys the rural setting.

How is Riverside Tappahanock different from other hospitalist groups you’ve worked at?

Answer: The thing I like about it is I get to wear a lot of different hats. We don’t have intensivists; we manage our own ventilators and do our own critical care. And we’re also limited by the number of specialists we have, so of course, anything that is too difficult for us to do we transfer out. I don’t manage consultants, which seems like what hospitalists at a lot of big hospitals do. I’m often wondering what those hospitalists are left doing. Here we have cardiologists available to us, and as far as other specialists go, we have one gastroenterologist and a part-time nephrologist. I like the fact that I’m actually treating and not just stepping back and watching others treat. I especially like the ICU. This way I get to do critical care, and I think do it fairly well.

What are the challenges at a rural hospital?

A: A number of people just assume that, since we are just a small hospital, we can’t be giving good care. They come through the doors and they immediately want us to transfer them to a bigger hospital.

Is there a need for more rural hospitalists?

A: There have been times in the past when we’ve had trouble getting people [recruits] to look at us just because of the location, although I think we’re in a great location. We’re not far from Richmond, not far from good things to do.

Is there a solution to the recruitment problem?

A: The bottom line is we need more primary care physicians. We’re pretty selective and we’ve managed to do well despite that.

How many patients, on average, do you see?

A: We average about five admissions a day. We tend to follow about eight patients at a time. We don’t really do shifts. We take call a quarter of the time, doing admissions for a 24-hour stretch, averaging seven or eight calls in a month. Then we round on our post call days, as well, and the days in between. On average, we take every third day call, with a week off each month. We work 90 hours a week—pretty awful hours. So this is clearly a drawback. There are only four of us here, so if one of us were taken ill, we’d either have to get a [temporary doctor] or pick up the slack.

What are the other drawbacks to a rural hospital?

A: Our denominators are so small that, if we miss aspirin on arrival for one patient, it can pull us from first to the fourth in quality ratings. Everything has to be perfect. We can’t make any omissions. I think it certainly adds to perception. People in small towns talk a lot, and what people talk about are things that did not go well. They don’t talk about things that did go well.

What advice do you have for those considering a position at a rural hospital?

A: You have to be willing to work more than you would at a larger hospital, but I think you get to do more, which is more rewarding from my point of view.

What can rural hospitalists teach other hospitalists?

A: We probably can teach workload management a bit better. I think we can also talk about quality referral patterns. The things we need to do to make sure our quality numbers are good are probably a lot more stringent because our capture needs to be better. TH

Think a big hospital is where it’s at? Not according to Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahanock Hospital, a 67-bed facility in rural Tappahannock, Va. The community is home to 2,172 residents and located about an hour east of Richmond, just up river from the Chesapeake Bay. Dr. Ferrance, a former chiropractor who has been practicing as a hospitalist at Riverside since 2002, recently spoke with The Hospitalist about why he enjoys the rural setting.

How is Riverside Tappahanock different from other hospitalist groups you’ve worked at?

Answer: The thing I like about it is I get to wear a lot of different hats. We don’t have intensivists; we manage our own ventilators and do our own critical care. And we’re also limited by the number of specialists we have, so of course, anything that is too difficult for us to do we transfer out. I don’t manage consultants, which seems like what hospitalists at a lot of big hospitals do. I’m often wondering what those hospitalists are left doing. Here we have cardiologists available to us, and as far as other specialists go, we have one gastroenterologist and a part-time nephrologist. I like the fact that I’m actually treating and not just stepping back and watching others treat. I especially like the ICU. This way I get to do critical care, and I think do it fairly well.

What are the challenges at a rural hospital?

A: A number of people just assume that, since we are just a small hospital, we can’t be giving good care. They come through the doors and they immediately want us to transfer them to a bigger hospital.

Is there a need for more rural hospitalists?

A: There have been times in the past when we’ve had trouble getting people [recruits] to look at us just because of the location, although I think we’re in a great location. We’re not far from Richmond, not far from good things to do.

Is there a solution to the recruitment problem?

A: The bottom line is we need more primary care physicians. We’re pretty selective and we’ve managed to do well despite that.

How many patients, on average, do you see?

A: We average about five admissions a day. We tend to follow about eight patients at a time. We don’t really do shifts. We take call a quarter of the time, doing admissions for a 24-hour stretch, averaging seven or eight calls in a month. Then we round on our post call days, as well, and the days in between. On average, we take every third day call, with a week off each month. We work 90 hours a week—pretty awful hours. So this is clearly a drawback. There are only four of us here, so if one of us were taken ill, we’d either have to get a [temporary doctor] or pick up the slack.

What are the other drawbacks to a rural hospital?

A: Our denominators are so small that, if we miss aspirin on arrival for one patient, it can pull us from first to the fourth in quality ratings. Everything has to be perfect. We can’t make any omissions. I think it certainly adds to perception. People in small towns talk a lot, and what people talk about are things that did not go well. They don’t talk about things that did go well.

What advice do you have for those considering a position at a rural hospital?

A: You have to be willing to work more than you would at a larger hospital, but I think you get to do more, which is more rewarding from my point of view.

What can rural hospitalists teach other hospitalists?

A: We probably can teach workload management a bit better. I think we can also talk about quality referral patterns. The things we need to do to make sure our quality numbers are good are probably a lot more stringent because our capture needs to be better. TH

Think a big hospital is where it’s at? Not according to Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahanock Hospital, a 67-bed facility in rural Tappahannock, Va. The community is home to 2,172 residents and located about an hour east of Richmond, just up river from the Chesapeake Bay. Dr. Ferrance, a former chiropractor who has been practicing as a hospitalist at Riverside since 2002, recently spoke with The Hospitalist about why he enjoys the rural setting.

How is Riverside Tappahanock different from other hospitalist groups you’ve worked at?

Answer: The thing I like about it is I get to wear a lot of different hats. We don’t have intensivists; we manage our own ventilators and do our own critical care. And we’re also limited by the number of specialists we have, so of course, anything that is too difficult for us to do we transfer out. I don’t manage consultants, which seems like what hospitalists at a lot of big hospitals do. I’m often wondering what those hospitalists are left doing. Here we have cardiologists available to us, and as far as other specialists go, we have one gastroenterologist and a part-time nephrologist. I like the fact that I’m actually treating and not just stepping back and watching others treat. I especially like the ICU. This way I get to do critical care, and I think do it fairly well.

What are the challenges at a rural hospital?

A: A number of people just assume that, since we are just a small hospital, we can’t be giving good care. They come through the doors and they immediately want us to transfer them to a bigger hospital.

Is there a need for more rural hospitalists?

A: There have been times in the past when we’ve had trouble getting people [recruits] to look at us just because of the location, although I think we’re in a great location. We’re not far from Richmond, not far from good things to do.

Is there a solution to the recruitment problem?

A: The bottom line is we need more primary care physicians. We’re pretty selective and we’ve managed to do well despite that.

How many patients, on average, do you see?

A: We average about five admissions a day. We tend to follow about eight patients at a time. We don’t really do shifts. We take call a quarter of the time, doing admissions for a 24-hour stretch, averaging seven or eight calls in a month. Then we round on our post call days, as well, and the days in between. On average, we take every third day call, with a week off each month. We work 90 hours a week—pretty awful hours. So this is clearly a drawback. There are only four of us here, so if one of us were taken ill, we’d either have to get a [temporary doctor] or pick up the slack.

What are the other drawbacks to a rural hospital?

A: Our denominators are so small that, if we miss aspirin on arrival for one patient, it can pull us from first to the fourth in quality ratings. Everything has to be perfect. We can’t make any omissions. I think it certainly adds to perception. People in small towns talk a lot, and what people talk about are things that did not go well. They don’t talk about things that did go well.

What advice do you have for those considering a position at a rural hospital?

A: You have to be willing to work more than you would at a larger hospital, but I think you get to do more, which is more rewarding from my point of view.

What can rural hospitalists teach other hospitalists?

A: We probably can teach workload management a bit better. I think we can also talk about quality referral patterns. The things we need to do to make sure our quality numbers are good are probably a lot more stringent because our capture needs to be better. TH

Brian Bossard, MD, was practicing as a hospitalist before he even knew what a hospitalist was. In 1993, Dr. Bossard, then a private practice internist, initiated a contract with Lincoln General Hospital in Lincoln, Neb. He agreed to care for hospital patients who didn’t have physicians. The hospital signed the contract—three years before HM pioneer Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California San Francisco, former SHM president and author of the blog “Wachter’s World” (www.wachtersworld.com), coined the term “hospitalist.”

Dr. Bossard, director and CEO of Inpatient Physician Associates in Lincoln, recently spoke with The Hospitalist about being at the forefront of the hospital medicine movement.

Q: How did you come to form your own hospitalist group?

A: [Starting in 1993], I was providing hospital medicine service while at the same time working in a private practice model. I took care of my own patients and also took care of all the assigned patients through the hospital. During that period, I started getting referrals from other physicians who wanted to turn their patients’ care over to me. It became clear after just a few years of doing that I was getting very busy and that there was a need for a more formal hospital medicine program. So, beginning in 1998, I started going to national hospital medicine meetings. I took my hospital administrator with me to the first meeting, and during the next four years developed an infrastructure for a mature hospital medicine program.

Q: What trends have you identified in HM since that time?

A: In the case of academic medicine models, hospital medicine developed because they needed to have a system to provide a cap for the residents—both in terms of number of hours they worked and the number of patients they saw. That was a new development and one that wasn’t in place when I went through training.

Private practice or community-based hospitals had physicians who were no longer interested in providing community call for taking care of patients that didn’t have physicians, or maybe didn’t have insurance. Community hospitals were finding that many physicians were opting out of that community call so they needed hospital medicine support to take care of those patients.

Q: What is the most significant change you’ve witnessed?

A: It’s become clear hospital medicine programs not only provide staffing to take care of those patients who otherwise wouldn’t be taken care of, but also provide a structure to take care of patients better. Probably the most positive and meaningful change since the mid-’90s is that hospital medicine programs are seen as quality drivers, efficiency drivers, and as a source of leadership within hospital policy making and decision making.

Q: What are your responsibilities as CEO of your group?

A: I run the business from top to bottom. Since I started the group in 2002, we’ve grown from just six physicians to 18 physicians and three nurse coordinators. So, I’ve had an opportunity during the last seven years to develop leadership roles within our group and delegate some activities to other leaders in the group. Where I once oversaw every little detail, I am now able to turn over some things to other, very talented group members. What I really focus on now is recruitment, the clinical aspects, public relations, and those sorts of things. But I never lose sight of the importance of developing data to drive our decisions, so I’m very involved in that, as well. As we add more and more physicians, I have to dedicate more time to management of the group. My clinical time goes down as the group grows.

Q: You mentioned that you collect data?

A: I work with the folks in the IT and Division Analysis departments in the hospital to identify what data we can get, what is important for me to know … so we can make decisions for the better of the group and the hospital. Some of that involves knowing what time of the day we have the highest admissions consults and what days of the week we’re busiest, and then organizing our schedule accordingly. It’s important to look at numbers and data, as opposed to going by when you feel you’re busy and when you’re not, because sometimes the feel is different from what is actually happening.

Q: What are the challenges facing your HMG?

A: Recruitment is a huge challenge. The growth of hospital medicine is much greater than anticipated even five years ago. Many programs are understaffed right now. That’s not because they don’t have financing, but because they don’t have physicians available to staff the slots. When I started my group, I was able to recruit a strong, core group of five physicians in six months. I don’t think there is any way you could do that now. That’s a trend that’s changed for the worst. I don’t think internal medicine is going to be able to support the need for care providers within hospital medicine programs.

Q: How should hospital medicine groups look to fill their vacancies?

A: I think opportunities will exist for well-trained and motivated family medicine physicians. Many more rural or community-based hospitals are turning to family physicians to staff programs. Typically, family physicians represent only 3% of hospital medicine program slots. I see that percentage increasing fairly significantly in the next five years. TH

Brian Bossard, MD, was practicing as a hospitalist before he even knew what a hospitalist was. In 1993, Dr. Bossard, then a private practice internist, initiated a contract with Lincoln General Hospital in Lincoln, Neb. He agreed to care for hospital patients who didn’t have physicians. The hospital signed the contract—three years before HM pioneer Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California San Francisco, former SHM president and author of the blog “Wachter’s World” (www.wachtersworld.com), coined the term “hospitalist.”

Dr. Bossard, director and CEO of Inpatient Physician Associates in Lincoln, recently spoke with The Hospitalist about being at the forefront of the hospital medicine movement.

Q: How did you come to form your own hospitalist group?

A: [Starting in 1993], I was providing hospital medicine service while at the same time working in a private practice model. I took care of my own patients and also took care of all the assigned patients through the hospital. During that period, I started getting referrals from other physicians who wanted to turn their patients’ care over to me. It became clear after just a few years of doing that I was getting very busy and that there was a need for a more formal hospital medicine program. So, beginning in 1998, I started going to national hospital medicine meetings. I took my hospital administrator with me to the first meeting, and during the next four years developed an infrastructure for a mature hospital medicine program.

Q: What trends have you identified in HM since that time?

A: In the case of academic medicine models, hospital medicine developed because they needed to have a system to provide a cap for the residents—both in terms of number of hours they worked and the number of patients they saw. That was a new development and one that wasn’t in place when I went through training.

Private practice or community-based hospitals had physicians who were no longer interested in providing community call for taking care of patients that didn’t have physicians, or maybe didn’t have insurance. Community hospitals were finding that many physicians were opting out of that community call so they needed hospital medicine support to take care of those patients.

Q: What is the most significant change you’ve witnessed?

A: It’s become clear hospital medicine programs not only provide staffing to take care of those patients who otherwise wouldn’t be taken care of, but also provide a structure to take care of patients better. Probably the most positive and meaningful change since the mid-’90s is that hospital medicine programs are seen as quality drivers, efficiency drivers, and as a source of leadership within hospital policy making and decision making.

Q: What are your responsibilities as CEO of your group?

A: I run the business from top to bottom. Since I started the group in 2002, we’ve grown from just six physicians to 18 physicians and three nurse coordinators. So, I’ve had an opportunity during the last seven years to develop leadership roles within our group and delegate some activities to other leaders in the group. Where I once oversaw every little detail, I am now able to turn over some things to other, very talented group members. What I really focus on now is recruitment, the clinical aspects, public relations, and those sorts of things. But I never lose sight of the importance of developing data to drive our decisions, so I’m very involved in that, as well. As we add more and more physicians, I have to dedicate more time to management of the group. My clinical time goes down as the group grows.

Q: You mentioned that you collect data?

A: I work with the folks in the IT and Division Analysis departments in the hospital to identify what data we can get, what is important for me to know … so we can make decisions for the better of the group and the hospital. Some of that involves knowing what time of the day we have the highest admissions consults and what days of the week we’re busiest, and then organizing our schedule accordingly. It’s important to look at numbers and data, as opposed to going by when you feel you’re busy and when you’re not, because sometimes the feel is different from what is actually happening.

Q: What are the challenges facing your HMG?

A: Recruitment is a huge challenge. The growth of hospital medicine is much greater than anticipated even five years ago. Many programs are understaffed right now. That’s not because they don’t have financing, but because they don’t have physicians available to staff the slots. When I started my group, I was able to recruit a strong, core group of five physicians in six months. I don’t think there is any way you could do that now. That’s a trend that’s changed for the worst. I don’t think internal medicine is going to be able to support the need for care providers within hospital medicine programs.

Q: How should hospital medicine groups look to fill their vacancies?

A: I think opportunities will exist for well-trained and motivated family medicine physicians. Many more rural or community-based hospitals are turning to family physicians to staff programs. Typically, family physicians represent only 3% of hospital medicine program slots. I see that percentage increasing fairly significantly in the next five years. TH

Brian Bossard, MD, was practicing as a hospitalist before he even knew what a hospitalist was. In 1993, Dr. Bossard, then a private practice internist, initiated a contract with Lincoln General Hospital in Lincoln, Neb. He agreed to care for hospital patients who didn’t have physicians. The hospital signed the contract—three years before HM pioneer Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California San Francisco, former SHM president and author of the blog “Wachter’s World” (www.wachtersworld.com), coined the term “hospitalist.”

Dr. Bossard, director and CEO of Inpatient Physician Associates in Lincoln, recently spoke with The Hospitalist about being at the forefront of the hospital medicine movement.

Q: How did you come to form your own hospitalist group?

A: [Starting in 1993], I was providing hospital medicine service while at the same time working in a private practice model. I took care of my own patients and also took care of all the assigned patients through the hospital. During that period, I started getting referrals from other physicians who wanted to turn their patients’ care over to me. It became clear after just a few years of doing that I was getting very busy and that there was a need for a more formal hospital medicine program. So, beginning in 1998, I started going to national hospital medicine meetings. I took my hospital administrator with me to the first meeting, and during the next four years developed an infrastructure for a mature hospital medicine program.

Q: What trends have you identified in HM since that time?

A: In the case of academic medicine models, hospital medicine developed because they needed to have a system to provide a cap for the residents—both in terms of number of hours they worked and the number of patients they saw. That was a new development and one that wasn’t in place when I went through training.

Private practice or community-based hospitals had physicians who were no longer interested in providing community call for taking care of patients that didn’t have physicians, or maybe didn’t have insurance. Community hospitals were finding that many physicians were opting out of that community call so they needed hospital medicine support to take care of those patients.

Q: What is the most significant change you’ve witnessed?

A: It’s become clear hospital medicine programs not only provide staffing to take care of those patients who otherwise wouldn’t be taken care of, but also provide a structure to take care of patients better. Probably the most positive and meaningful change since the mid-’90s is that hospital medicine programs are seen as quality drivers, efficiency drivers, and as a source of leadership within hospital policy making and decision making.

Q: What are your responsibilities as CEO of your group?

A: I run the business from top to bottom. Since I started the group in 2002, we’ve grown from just six physicians to 18 physicians and three nurse coordinators. So, I’ve had an opportunity during the last seven years to develop leadership roles within our group and delegate some activities to other leaders in the group. Where I once oversaw every little detail, I am now able to turn over some things to other, very talented group members. What I really focus on now is recruitment, the clinical aspects, public relations, and those sorts of things. But I never lose sight of the importance of developing data to drive our decisions, so I’m very involved in that, as well. As we add more and more physicians, I have to dedicate more time to management of the group. My clinical time goes down as the group grows.

Q: You mentioned that you collect data?

A: I work with the folks in the IT and Division Analysis departments in the hospital to identify what data we can get, what is important for me to know … so we can make decisions for the better of the group and the hospital. Some of that involves knowing what time of the day we have the highest admissions consults and what days of the week we’re busiest, and then organizing our schedule accordingly. It’s important to look at numbers and data, as opposed to going by when you feel you’re busy and when you’re not, because sometimes the feel is different from what is actually happening.

Q: What are the challenges facing your HMG?

A: Recruitment is a huge challenge. The growth of hospital medicine is much greater than anticipated even five years ago. Many programs are understaffed right now. That’s not because they don’t have financing, but because they don’t have physicians available to staff the slots. When I started my group, I was able to recruit a strong, core group of five physicians in six months. I don’t think there is any way you could do that now. That’s a trend that’s changed for the worst. I don’t think internal medicine is going to be able to support the need for care providers within hospital medicine programs.

Q: How should hospital medicine groups look to fill their vacancies?

A: I think opportunities will exist for well-trained and motivated family medicine physicians. Many more rural or community-based hospitals are turning to family physicians to staff programs. Typically, family physicians represent only 3% of hospital medicine program slots. I see that percentage increasing fairly significantly in the next five years. TH

(Maj) Heather Cereste, MD, chair of the Bioethics Committee at Wilford Hall Medical Center at Lackland Air Force Base near San Antonio, Texas, and a member of Team Hospitalist, is the only geriatric-trained internist in the U.S. Air Force. From January through May 2007, she served as the attending primary care physician at Balad Trauma Hospital in Balad, Iraq. She recently spoke with The Hospitalist about her experience as a wartime physician.

Q: What motivated you to join the Air Force?

A: I talked to the Air Force near end of third year in residency. A number of things played into my decision. I was in Manhattan during 9/11 and got caught up in the surge of patriotism. I had thought about the military before, and was at a point when I was about to enter geriatrics and wasn’t sure if wanted to go into the traditional workforce or explore something else. I joined the reserves in 2004 and went active in 2006. To be honest with you, I never thought I would be deployed to a combat zone.

Q: What type of training did you receive before going to Iraq?

A: I was just undergoing the credentialing process when I was asked by my commander [to] deploy with her in a few months. I was a little shocked and taken aback, and didn’t feel at all prepared. So I inquired about further training and was referred to the shock trauma group in Baltimore, Md. It was the closest I could get to warfare type of injuries because it’s an urban warfare they fight in Baltimore. There, I was able to gain confidence in doing some procedures, including chest tubes, and refreshing myself about central lines and the acuity of care.

Q: What was it like working in Iraq?

PHOTOS COURTESY OF Heather Cereste, MD

A: Our team worked seven days a week in the intensive care unit. We were on call every fifth night, overnight. We took care of the critically ill patients who came in through ER or who were directed to us. For the most part, we interacted with the coalition people for only 24–48 hours before they were transported out. The American and British people often went to Germany for more definitive care.

Q: What medical conditions did you see?

A: Over five months we managed about 528 critically ill people. There were certainly a lot of postoperative cases. We took care of burns and head wounds, which were increasing in number, a lot of limb amputations, as well as blast injuries and gunshot wounds. Civilians would present at our gates and we could triage them, if we had enough room.

Q: Did you feel like you were in a war zone?

A: It was very surreal. I was one of the last rotations to go when it was a tent hospital, so when we had rain and weather, we’d have to deal with floods, etc. It was a very rustic environment; there was dust was everywhere. The helicopters would come in and land right outside our tents.

Our hospital was right next to the wire–that’s a barbed wire fence that separated our base from the outside of the base–so we heard machine guns constantly while we were doing our rounds. We also got mortared frequently. Disgruntled people on the other side would set up across the river. They had some Russian mortars that they would throw over to our side. Whenever we could identify that the mortars were coming over the wall, sirens would go off and we’d have to dive for cover.

You’re constantly reminded of war, if not by the sounds, than certainly with the injuries. And people were carrying their guns all the time. It was strange to be a physician carrying a gun.

Q: How did your background in geriatrics come into play?

A: Believe it or not, many of the Iraqi civilians we treated were not chronically aged, but were physiology aged. We saw a lot of geriatric syndromes, even in 45-year-olds. Diet and access to care were common issues.

Q: Did you have enough resources?

A: As far as combat hospitals go, in my limited experience, I think we had excellent resources. But sometimes, if patients required extended intensive care and if we didn’t have the dialysis or the level of burn care, we just couldn’t treat them. It was a challenge every day to deal with certain patients who we knew under normal circumstances we could take care of, but because of the circumstance we had to stop care. That made it really hard.

Q: Is there one case that stands out as an example of what can be done in a combat zone?

A: There was one young baby who was a medical case. He was 28 days old when he first presented. He came to the gate with his parents with an infected arm. He had been seen at an outside facility and was treated for some kind of infection.

We thought from an initial admitting diagnosis that he had pericardial infusion. He had a long, protracted course where he required intubation. He was quite the enigma, and required a lot of attention and care and resources. Everyone at the hospital, from the nursing staff, to the medical technicians, to chaplains, would stop by say hello to the baby. We all did our best to keep him alive. He ended up getting discharged; the last we heard he was doing all right. My hope is that he would grow very strong.

It was nice to have a child around. It was also great because the family had entrusted us to take care of him. They seemed grateful when they were finally able to take him home.

Q: Would you go back?

A: Definitely. It was probably the most amazing experience in my life, professional and personally. It’s a wonderful place to do medicine because you’re forced to practice outside your comfort zone. You also feel that your efforts are playing a positive role. You get out of that whole humdrum, “beaten-by-the-system” feeling that I think people may feel here. I got to meet interesting people and be a part of history. And I survived, so that was good. TH

(Maj) Heather Cereste, MD, chair of the Bioethics Committee at Wilford Hall Medical Center at Lackland Air Force Base near San Antonio, Texas, and a member of Team Hospitalist, is the only geriatric-trained internist in the U.S. Air Force. From January through May 2007, she served as the attending primary care physician at Balad Trauma Hospital in Balad, Iraq. She recently spoke with The Hospitalist about her experience as a wartime physician.

Q: What motivated you to join the Air Force?

A: I talked to the Air Force near end of third year in residency. A number of things played into my decision. I was in Manhattan during 9/11 and got caught up in the surge of patriotism. I had thought about the military before, and was at a point when I was about to enter geriatrics and wasn’t sure if wanted to go into the traditional workforce or explore something else. I joined the reserves in 2004 and went active in 2006. To be honest with you, I never thought I would be deployed to a combat zone.

Q: What type of training did you receive before going to Iraq?

A: I was just undergoing the credentialing process when I was asked by my commander [to] deploy with her in a few months. I was a little shocked and taken aback, and didn’t feel at all prepared. So I inquired about further training and was referred to the shock trauma group in Baltimore, Md. It was the closest I could get to warfare type of injuries because it’s an urban warfare they fight in Baltimore. There, I was able to gain confidence in doing some procedures, including chest tubes, and refreshing myself about central lines and the acuity of care.

Q: What was it like working in Iraq?

PHOTOS COURTESY OF Heather Cereste, MD

A: Our team worked seven days a week in the intensive care unit. We were on call every fifth night, overnight. We took care of the critically ill patients who came in through ER or who were directed to us. For the most part, we interacted with the coalition people for only 24–48 hours before they were transported out. The American and British people often went to Germany for more definitive care.

Q: What medical conditions did you see?

A: Over five months we managed about 528 critically ill people. There were certainly a lot of postoperative cases. We took care of burns and head wounds, which were increasing in number, a lot of limb amputations, as well as blast injuries and gunshot wounds. Civilians would present at our gates and we could triage them, if we had enough room.

Q: Did you feel like you were in a war zone?

A: It was very surreal. I was one of the last rotations to go when it was a tent hospital, so when we had rain and weather, we’d have to deal with floods, etc. It was a very rustic environment; there was dust was everywhere. The helicopters would come in and land right outside our tents.

Our hospital was right next to the wire–that’s a barbed wire fence that separated our base from the outside of the base–so we heard machine guns constantly while we were doing our rounds. We also got mortared frequently. Disgruntled people on the other side would set up across the river. They had some Russian mortars that they would throw over to our side. Whenever we could identify that the mortars were coming over the wall, sirens would go off and we’d have to dive for cover.

You’re constantly reminded of war, if not by the sounds, than certainly with the injuries. And people were carrying their guns all the time. It was strange to be a physician carrying a gun.

Q: How did your background in geriatrics come into play?

A: Believe it or not, many of the Iraqi civilians we treated were not chronically aged, but were physiology aged. We saw a lot of geriatric syndromes, even in 45-year-olds. Diet and access to care were common issues.

Q: Did you have enough resources?

A: As far as combat hospitals go, in my limited experience, I think we had excellent resources. But sometimes, if patients required extended intensive care and if we didn’t have the dialysis or the level of burn care, we just couldn’t treat them. It was a challenge every day to deal with certain patients who we knew under normal circumstances we could take care of, but because of the circumstance we had to stop care. That made it really hard.

Q: Is there one case that stands out as an example of what can be done in a combat zone?

A: There was one young baby who was a medical case. He was 28 days old when he first presented. He came to the gate with his parents with an infected arm. He had been seen at an outside facility and was treated for some kind of infection.

We thought from an initial admitting diagnosis that he had pericardial infusion. He had a long, protracted course where he required intubation. He was quite the enigma, and required a lot of attention and care and resources. Everyone at the hospital, from the nursing staff, to the medical technicians, to chaplains, would stop by say hello to the baby. We all did our best to keep him alive. He ended up getting discharged; the last we heard he was doing all right. My hope is that he would grow very strong.

It was nice to have a child around. It was also great because the family had entrusted us to take care of him. They seemed grateful when they were finally able to take him home.

Q: Would you go back?

A: Definitely. It was probably the most amazing experience in my life, professional and personally. It’s a wonderful place to do medicine because you’re forced to practice outside your comfort zone. You also feel that your efforts are playing a positive role. You get out of that whole humdrum, “beaten-by-the-system” feeling that I think people may feel here. I got to meet interesting people and be a part of history. And I survived, so that was good. TH

(Maj) Heather Cereste, MD, chair of the Bioethics Committee at Wilford Hall Medical Center at Lackland Air Force Base near San Antonio, Texas, and a member of Team Hospitalist, is the only geriatric-trained internist in the U.S. Air Force. From January through May 2007, she served as the attending primary care physician at Balad Trauma Hospital in Balad, Iraq. She recently spoke with The Hospitalist about her experience as a wartime physician.

Q: What motivated you to join the Air Force?

A: I talked to the Air Force near end of third year in residency. A number of things played into my decision. I was in Manhattan during 9/11 and got caught up in the surge of patriotism. I had thought about the military before, and was at a point when I was about to enter geriatrics and wasn’t sure if wanted to go into the traditional workforce or explore something else. I joined the reserves in 2004 and went active in 2006. To be honest with you, I never thought I would be deployed to a combat zone.

Q: What type of training did you receive before going to Iraq?

A: I was just undergoing the credentialing process when I was asked by my commander [to] deploy with her in a few months. I was a little shocked and taken aback, and didn’t feel at all prepared. So I inquired about further training and was referred to the shock trauma group in Baltimore, Md. It was the closest I could get to warfare type of injuries because it’s an urban warfare they fight in Baltimore. There, I was able to gain confidence in doing some procedures, including chest tubes, and refreshing myself about central lines and the acuity of care.

Q: What was it like working in Iraq?

PHOTOS COURTESY OF Heather Cereste, MD

A: Our team worked seven days a week in the intensive care unit. We were on call every fifth night, overnight. We took care of the critically ill patients who came in through ER or who were directed to us. For the most part, we interacted with the coalition people for only 24–48 hours before they were transported out. The American and British people often went to Germany for more definitive care.

Q: What medical conditions did you see?

A: Over five months we managed about 528 critically ill people. There were certainly a lot of postoperative cases. We took care of burns and head wounds, which were increasing in number, a lot of limb amputations, as well as blast injuries and gunshot wounds. Civilians would present at our gates and we could triage them, if we had enough room.

Q: Did you feel like you were in a war zone?

A: It was very surreal. I was one of the last rotations to go when it was a tent hospital, so when we had rain and weather, we’d have to deal with floods, etc. It was a very rustic environment; there was dust was everywhere. The helicopters would come in and land right outside our tents.

Our hospital was right next to the wire–that’s a barbed wire fence that separated our base from the outside of the base–so we heard machine guns constantly while we were doing our rounds. We also got mortared frequently. Disgruntled people on the other side would set up across the river. They had some Russian mortars that they would throw over to our side. Whenever we could identify that the mortars were coming over the wall, sirens would go off and we’d have to dive for cover.

You’re constantly reminded of war, if not by the sounds, than certainly with the injuries. And people were carrying their guns all the time. It was strange to be a physician carrying a gun.

Q: How did your background in geriatrics come into play?

A: Believe it or not, many of the Iraqi civilians we treated were not chronically aged, but were physiology aged. We saw a lot of geriatric syndromes, even in 45-year-olds. Diet and access to care were common issues.

Q: Did you have enough resources?

A: As far as combat hospitals go, in my limited experience, I think we had excellent resources. But sometimes, if patients required extended intensive care and if we didn’t have the dialysis or the level of burn care, we just couldn’t treat them. It was a challenge every day to deal with certain patients who we knew under normal circumstances we could take care of, but because of the circumstance we had to stop care. That made it really hard.

Q: Is there one case that stands out as an example of what can be done in a combat zone?

A: There was one young baby who was a medical case. He was 28 days old when he first presented. He came to the gate with his parents with an infected arm. He had been seen at an outside facility and was treated for some kind of infection.

We thought from an initial admitting diagnosis that he had pericardial infusion. He had a long, protracted course where he required intubation. He was quite the enigma, and required a lot of attention and care and resources. Everyone at the hospital, from the nursing staff, to the medical technicians, to chaplains, would stop by say hello to the baby. We all did our best to keep him alive. He ended up getting discharged; the last we heard he was doing all right. My hope is that he would grow very strong.

It was nice to have a child around. It was also great because the family had entrusted us to take care of him. They seemed grateful when they were finally able to take him home.

Q: Would you go back?

A: Definitely. It was probably the most amazing experience in my life, professional and personally. It’s a wonderful place to do medicine because you’re forced to practice outside your comfort zone. You also feel that your efforts are playing a positive role. You get out of that whole humdrum, “beaten-by-the-system” feeling that I think people may feel here. I got to meet interesting people and be a part of history. And I survived, so that was good. TH