Practice Economics

SHM board member Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., says there is no easy way to know when it is the right time to grow. He offers four tips to hospitalist group leaders grappling with the question:

• Benchmark: Use the SHM survey, MGMA data, or local analyses to determine best practices. But don’t be a slave to data that don’t account for the particulars of your payor mix, patient population, etc.
• Network: Meet with group leaders in nearby practices. Talk to administrators. Understand the competitive set for your hospital and know what their data sets are.
• Communicate: Talk to doctors, C-suite executives, and everyone in between. Front-line physicians and nurses often know better than practice heads which resources are needed, and where.
• Stay flexible: Don’t be wedded to needing to grow. Maybe a group has physicians who want extra shifts to handle a new schedule. Maybe the installation of new technology will improve efficiency and eliminate the need for a new physician.

SHM board member Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., says there is no easy way to know when it is the right time to grow. He offers four tips to hospitalist group leaders grappling with the question:

• Benchmark: Use the SHM survey, MGMA data, or local analyses to determine best practices. But don’t be a slave to data that don’t account for the particulars of your payor mix, patient population, etc.
• Network: Meet with group leaders in nearby practices. Talk to administrators. Understand the competitive set for your hospital and know what their data sets are.
• Communicate: Talk to doctors, C-suite executives, and everyone in between. Front-line physicians and nurses often know better than practice heads which resources are needed, and where.
• Stay flexible: Don’t be wedded to needing to grow. Maybe a group has physicians who want extra shifts to handle a new schedule. Maybe the installation of new technology will improve efficiency and eliminate the need for a new physician.

SHM board member Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., says there is no easy way to know when it is the right time to grow. He offers four tips to hospitalist group leaders grappling with the question:

• Benchmark: Use the SHM survey, MGMA data, or local analyses to determine best practices. But don’t be a slave to data that don’t account for the particulars of your payor mix, patient population, etc.
• Network: Meet with group leaders in nearby practices. Talk to administrators. Understand the competitive set for your hospital and know what their data sets are.
• Communicate: Talk to doctors, C-suite executives, and everyone in between. Front-line physicians and nurses often know better than practice heads which resources are needed, and where.
• Stay flexible: Don’t be wedded to needing to grow. Maybe a group has physicians who want extra shifts to handle a new schedule. Maybe the installation of new technology will improve efficiency and eliminate the need for a new physician.

Reliability. This sounds like a decent trait. Who wouldn’t want to be described as “reliable”? It sounds reputable whether you’re a person, a car, or a dishwasher. So how does one become or emulate the trait of being reliable, one who is predictable, punctua—“reproducible,” if you will?

Organizational reliability has received a fair bit of press these days. The industries that have come to embrace reliability concepts are those in which failure is easy to come by, and those in which failure is likely to be catastrophic if it occurs. In the medical industry, failure occurs to people, not widgets or machines, so by definition it tends to be catastrophic. These failures generally come in three flavors:

• The expected fails to occur (i.e. a patient with pneumonia does not receive their antibiotics on time);
• The unexpected occurs (i.e. a patient falls and breaks their hip); or
• The unexpected was not previously thought of (i.e. low-risk patient has a PEA arrest).

A fair bit of research has been done on how organizations can become more reliable. In their book “Managing the Unexpected: Assuring High Performance in an Age of Complexity,”¹ Karl Weick and Kathleen Sutcliffe studied firefighting, workers on aircraft carriers, and nuclear power plant employees. They all have in common the fundamental similarity that failure in their workplace is catastrophically dangerous, and that they must continuously strive to reduce the risk and/or mitigate effectively. The Agency for Healthcare Research and Quality (AHRQ) specifically studied, through case studies and site visits, how some healthcare organizations have achieved some success in the different domains of reliability.²

What both studies found is that there are five prerequisites that, if done well, lead to an organizational “state of mindfulness.” What they and others have found in their research of highly reliable organizations (HROs) is not that they have failure-free operations, but that they continuously and “mindfully” think about how to be failure-free. Inattention and complacency are the biggest threats to reliability.

The Fundamentals

The first prerequisite is sensitivity to operations. This refers to actively seeking information on how things actually are working, instead of how they are supposed to be working. It is being acutely aware of all operations, including the smallest details: Does the patient have an armband on? Is the nurse washing their hands? Is the whiteboard information correct? Is the bed alarm enabled? It is the state of mind when everyone knows how things should work, look, feel, sound, and can recognize when something is out of bounds.

The next prerequisite is a preoccupation with failure. This refers to a system in which failure and near-misses are completely transparent, and openly and honestly discussed (without inciting individual blame or punitive action), and learned from communally. This “group thought” continually reaffirms the fact that systems, and everyone in them, are completely fallible to errors. It is the complete opposite of inattention and complacency. It is continuously asking “What can go wrong, how can it go wrong, when will it go wrong, and how can I stop it?”

The next prerequisite is reluctance to oversimplify. This does not imply that simplicity is bad, but that oversimplicity is lethal. It forces people and organizations to avoid shortcuts and to not rely on simplistic explanations for situations that need to be complicated. Think of this as making a complicated soufflé; if you leave out a step or an ingredient, the product will be far from a soufflé.

The next prerequisite is deference to expertise. This principle recognizes that authority and/or rank are not equivalent to expertise. This assumes that people and organizations are willing and able to defer decision-making to the person who will make the best decision, not to who ranks highest in the organizational chart. A junior hospitalist might be much more likely to make a good decision on building a new order set than the hospitalist director is.

The last prerequisite is resilience. Webster’s defines resilience as “the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress … an ability to recover from or adjust easily to misfortune or change.” The “compressive stresses” and “misfortune or change” can present in a number of different ways, including bad patient outcomes, bad national press, or bad hospital rankings. A good HRO is not one that does not experience unexpected events, but is one that is not disabled by them. They routinely train and practice for worst-case scenarios. It is easy to “audit” resilience by looking at the organizational response to unexpected events. Are they handled with grace, ease, and speed, or with panic, anxiety, and ongoing uncertainty? Resilience involves adequately functioning despite adversity, recovering well, and learning from the experience.

Take-Home Message

The first three principles relate to how organizations can anticipate and reduce the risk of failure; the last two principles relate to how organizations mitigate the extent or severity of failure when it occurs. Together, they create the state of mindfulness, in which all senses are open and alert for signs of aberrations in the system, and where there is continuous learning of how to make the system function better.

What does this mean for a hospitalist to function in an HRO? Most hospitalists are on the front lines, where they routinely see where and how things can fail. They need to resist the urge to become complacent and remain continuously alert to signals that the system is not functioning for the safety of the patient. And when things do go awry, they need to be part of the resilience plan, to work with their teams to swiftly and effectively mitigate ongoing risks, and defer decision to expertise and not necessarily authority.

It also requires that each of us work within multidisciplinary teams in which all members add to the “state of mindfulness,” including the patient and their families (who very often note “aberrancies” before anyone else does). Think of your hospital as ascribed by Gordon Bethune, the former CEO of Continental Airlines. When asked why all employees received a bonus for on-time departure (instead of only employees on the front line), he held up his wristwatch and said, “What part of this watch don’t you think we need?”

Hospitalists can be powerful motivators for a culture change that empowers all hospital employees to be engaged in anticipating and managing failures—just by being mindful. This is a great place to start.

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. Email her at scheured@musc.edu.

References

1. Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in an age of uncertainty, 2nd ed. 2007: Hoboken, NJ: John Wiley & Sons Inc.
2. Agency for Healthcare Research and Quality. Becoming a high reliability organization: operational advice for hospital leaders. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/qual/hroadvice/. Accessed Dec. 10, 2012.

Reliability. This sounds like a decent trait. Who wouldn’t want to be described as “reliable”? It sounds reputable whether you’re a person, a car, or a dishwasher. So how does one become or emulate the trait of being reliable, one who is predictable, punctua—“reproducible,” if you will?

Organizational reliability has received a fair bit of press these days. The industries that have come to embrace reliability concepts are those in which failure is easy to come by, and those in which failure is likely to be catastrophic if it occurs. In the medical industry, failure occurs to people, not widgets or machines, so by definition it tends to be catastrophic. These failures generally come in three flavors:

• The expected fails to occur (i.e. a patient with pneumonia does not receive their antibiotics on time);
• The unexpected occurs (i.e. a patient falls and breaks their hip); or
• The unexpected was not previously thought of (i.e. low-risk patient has a PEA arrest).

A fair bit of research has been done on how organizations can become more reliable. In their book “Managing the Unexpected: Assuring High Performance in an Age of Complexity,”¹ Karl Weick and Kathleen Sutcliffe studied firefighting, workers on aircraft carriers, and nuclear power plant employees. They all have in common the fundamental similarity that failure in their workplace is catastrophically dangerous, and that they must continuously strive to reduce the risk and/or mitigate effectively. The Agency for Healthcare Research and Quality (AHRQ) specifically studied, through case studies and site visits, how some healthcare organizations have achieved some success in the different domains of reliability.²

What both studies found is that there are five prerequisites that, if done well, lead to an organizational “state of mindfulness.” What they and others have found in their research of highly reliable organizations (HROs) is not that they have failure-free operations, but that they continuously and “mindfully” think about how to be failure-free. Inattention and complacency are the biggest threats to reliability.

The Fundamentals

The first prerequisite is sensitivity to operations. This refers to actively seeking information on how things actually are working, instead of how they are supposed to be working. It is being acutely aware of all operations, including the smallest details: Does the patient have an armband on? Is the nurse washing their hands? Is the whiteboard information correct? Is the bed alarm enabled? It is the state of mind when everyone knows how things should work, look, feel, sound, and can recognize when something is out of bounds.

The next prerequisite is a preoccupation with failure. This refers to a system in which failure and near-misses are completely transparent, and openly and honestly discussed (without inciting individual blame or punitive action), and learned from communally. This “group thought” continually reaffirms the fact that systems, and everyone in them, are completely fallible to errors. It is the complete opposite of inattention and complacency. It is continuously asking “What can go wrong, how can it go wrong, when will it go wrong, and how can I stop it?”

The next prerequisite is reluctance to oversimplify. This does not imply that simplicity is bad, but that oversimplicity is lethal. It forces people and organizations to avoid shortcuts and to not rely on simplistic explanations for situations that need to be complicated. Think of this as making a complicated soufflé; if you leave out a step or an ingredient, the product will be far from a soufflé.

The next prerequisite is deference to expertise. This principle recognizes that authority and/or rank are not equivalent to expertise. This assumes that people and organizations are willing and able to defer decision-making to the person who will make the best decision, not to who ranks highest in the organizational chart. A junior hospitalist might be much more likely to make a good decision on building a new order set than the hospitalist director is.

The last prerequisite is resilience. Webster’s defines resilience as “the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress … an ability to recover from or adjust easily to misfortune or change.” The “compressive stresses” and “misfortune or change” can present in a number of different ways, including bad patient outcomes, bad national press, or bad hospital rankings. A good HRO is not one that does not experience unexpected events, but is one that is not disabled by them. They routinely train and practice for worst-case scenarios. It is easy to “audit” resilience by looking at the organizational response to unexpected events. Are they handled with grace, ease, and speed, or with panic, anxiety, and ongoing uncertainty? Resilience involves adequately functioning despite adversity, recovering well, and learning from the experience.

Take-Home Message

The first three principles relate to how organizations can anticipate and reduce the risk of failure; the last two principles relate to how organizations mitigate the extent or severity of failure when it occurs. Together, they create the state of mindfulness, in which all senses are open and alert for signs of aberrations in the system, and where there is continuous learning of how to make the system function better.

What does this mean for a hospitalist to function in an HRO? Most hospitalists are on the front lines, where they routinely see where and how things can fail. They need to resist the urge to become complacent and remain continuously alert to signals that the system is not functioning for the safety of the patient. And when things do go awry, they need to be part of the resilience plan, to work with their teams to swiftly and effectively mitigate ongoing risks, and defer decision to expertise and not necessarily authority.

It also requires that each of us work within multidisciplinary teams in which all members add to the “state of mindfulness,” including the patient and their families (who very often note “aberrancies” before anyone else does). Think of your hospital as ascribed by Gordon Bethune, the former CEO of Continental Airlines. When asked why all employees received a bonus for on-time departure (instead of only employees on the front line), he held up his wristwatch and said, “What part of this watch don’t you think we need?”

Hospitalists can be powerful motivators for a culture change that empowers all hospital employees to be engaged in anticipating and managing failures—just by being mindful. This is a great place to start.

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. Email her at scheured@musc.edu.

References

1. Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in an age of uncertainty, 2nd ed. 2007: Hoboken, NJ: John Wiley & Sons Inc.
2. Agency for Healthcare Research and Quality. Becoming a high reliability organization: operational advice for hospital leaders. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/qual/hroadvice/. Accessed Dec. 10, 2012.

Reliability. This sounds like a decent trait. Who wouldn’t want to be described as “reliable”? It sounds reputable whether you’re a person, a car, or a dishwasher. So how does one become or emulate the trait of being reliable, one who is predictable, punctua—“reproducible,” if you will?

Organizational reliability has received a fair bit of press these days. The industries that have come to embrace reliability concepts are those in which failure is easy to come by, and those in which failure is likely to be catastrophic if it occurs. In the medical industry, failure occurs to people, not widgets or machines, so by definition it tends to be catastrophic. These failures generally come in three flavors:

• The expected fails to occur (i.e. a patient with pneumonia does not receive their antibiotics on time);
• The unexpected occurs (i.e. a patient falls and breaks their hip); or
• The unexpected was not previously thought of (i.e. low-risk patient has a PEA arrest).

A fair bit of research has been done on how organizations can become more reliable. In their book “Managing the Unexpected: Assuring High Performance in an Age of Complexity,”¹ Karl Weick and Kathleen Sutcliffe studied firefighting, workers on aircraft carriers, and nuclear power plant employees. They all have in common the fundamental similarity that failure in their workplace is catastrophically dangerous, and that they must continuously strive to reduce the risk and/or mitigate effectively. The Agency for Healthcare Research and Quality (AHRQ) specifically studied, through case studies and site visits, how some healthcare organizations have achieved some success in the different domains of reliability.²

What both studies found is that there are five prerequisites that, if done well, lead to an organizational “state of mindfulness.” What they and others have found in their research of highly reliable organizations (HROs) is not that they have failure-free operations, but that they continuously and “mindfully” think about how to be failure-free. Inattention and complacency are the biggest threats to reliability.

The Fundamentals

The first prerequisite is sensitivity to operations. This refers to actively seeking information on how things actually are working, instead of how they are supposed to be working. It is being acutely aware of all operations, including the smallest details: Does the patient have an armband on? Is the nurse washing their hands? Is the whiteboard information correct? Is the bed alarm enabled? It is the state of mind when everyone knows how things should work, look, feel, sound, and can recognize when something is out of bounds.

The next prerequisite is a preoccupation with failure. This refers to a system in which failure and near-misses are completely transparent, and openly and honestly discussed (without inciting individual blame or punitive action), and learned from communally. This “group thought” continually reaffirms the fact that systems, and everyone in them, are completely fallible to errors. It is the complete opposite of inattention and complacency. It is continuously asking “What can go wrong, how can it go wrong, when will it go wrong, and how can I stop it?”

The next prerequisite is reluctance to oversimplify. This does not imply that simplicity is bad, but that oversimplicity is lethal. It forces people and organizations to avoid shortcuts and to not rely on simplistic explanations for situations that need to be complicated. Think of this as making a complicated soufflé; if you leave out a step or an ingredient, the product will be far from a soufflé.

The next prerequisite is deference to expertise. This principle recognizes that authority and/or rank are not equivalent to expertise. This assumes that people and organizations are willing and able to defer decision-making to the person who will make the best decision, not to who ranks highest in the organizational chart. A junior hospitalist might be much more likely to make a good decision on building a new order set than the hospitalist director is.

The last prerequisite is resilience. Webster’s defines resilience as “the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress … an ability to recover from or adjust easily to misfortune or change.” The “compressive stresses” and “misfortune or change” can present in a number of different ways, including bad patient outcomes, bad national press, or bad hospital rankings. A good HRO is not one that does not experience unexpected events, but is one that is not disabled by them. They routinely train and practice for worst-case scenarios. It is easy to “audit” resilience by looking at the organizational response to unexpected events. Are they handled with grace, ease, and speed, or with panic, anxiety, and ongoing uncertainty? Resilience involves adequately functioning despite adversity, recovering well, and learning from the experience.

Take-Home Message

The first three principles relate to how organizations can anticipate and reduce the risk of failure; the last two principles relate to how organizations mitigate the extent or severity of failure when it occurs. Together, they create the state of mindfulness, in which all senses are open and alert for signs of aberrations in the system, and where there is continuous learning of how to make the system function better.

What does this mean for a hospitalist to function in an HRO? Most hospitalists are on the front lines, where they routinely see where and how things can fail. They need to resist the urge to become complacent and remain continuously alert to signals that the system is not functioning for the safety of the patient. And when things do go awry, they need to be part of the resilience plan, to work with their teams to swiftly and effectively mitigate ongoing risks, and defer decision to expertise and not necessarily authority.

It also requires that each of us work within multidisciplinary teams in which all members add to the “state of mindfulness,” including the patient and their families (who very often note “aberrancies” before anyone else does). Think of your hospital as ascribed by Gordon Bethune, the former CEO of Continental Airlines. When asked why all employees received a bonus for on-time departure (instead of only employees on the front line), he held up his wristwatch and said, “What part of this watch don’t you think we need?”

Hospitalists can be powerful motivators for a culture change that empowers all hospital employees to be engaged in anticipating and managing failures—just by being mindful. This is a great place to start.

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. Email her at scheured@musc.edu.

References

1. Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in an age of uncertainty, 2nd ed. 2007: Hoboken, NJ: John Wiley & Sons Inc.
2. Agency for Healthcare Research and Quality. Becoming a high reliability organization: operational advice for hospital leaders. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/qual/hroadvice/. Accessed Dec. 10, 2012.

Ilan Alhadeff, MD, SFHM, program medical director for Cogent HMG at Hackensack University Medical Center in Hackensack, N.J., pays a lot of attention to the work relative-value units (wRVUs) his hospitalists are producing and the number of encounters they’re tallying. But he’s not particularly worried about what he sees on a daily, weekly, or even monthly basis; he takes a monthslong view of his data when he wants to forecast whether he is going to need to think about adding staff.

“When you look at months, you can start seeing trends,” Dr. Alhadeff says. “Let’s say there’s 16 to 18 average encounters. If your average is 16, you’re saying, ‘OK, you’re on the lower end of your normal.’ And if your average is 18, you’re on the higher end of normal. But if you start seeing 18 every month, odds are you’re going to start getting to 19. So at that point, that’s raising the thought that we need to start thinking about bringing someone else on.”

Dr. Alhadeff

It’s a dance HM group leaders around the country have to do when confronted with the age-old question: Should we expand our service? The answer is more art than science, experts say, as there is no standardized formula for knowing when your HM group should request more support from administration to add an FTE—or two or three. And, in a nod to the HM adage that if you’ve seen one HM group (HMG), then you’ve seen one HMG, the roadmap to expansion varies from place to place. But in a series of interviews with The Hospitalist, physicians, consultants, and management experts suggest there are broad themes that guide the process, including:

• Data. Dashboard metrics, such as average daily census (ADC), wRVUs, patient encounters, and length of stay (LOS), must be quantified. No discussion on expansion can be intelligibly made without a firm understanding of where a practice currently stands.
• Benchmarking. Collating figures isn’t enough. Measure your group against other local HMGs, regional groups, and national standards. SHM’s 2012 State of Hospital Medicine report is a good place to start.
• Scope or schedule. Pushing into new business lines (e.g. orthopedic comanagement) often requires new staff, as does adding shifts to provide 24-hour on-site coverage. Those arguments are different from the case to be made for expanding based on increased patient encounters.
• Physician buy-in. Group leaders cannot unilaterally determine it’s time to add staff, particularly in small-group settings in which hiring a new physician means taking revenue away from the existing group, if only in the short term. Talk with group members before embarking on expansion. Keep track of physician turnover. If hospitalists are leaving often, it could be a sign the group is understaffed.
• Administrative buy-in. If a group leader’s request for a new hire comes without months of conversation ahead of it, it’s likely too late. Prepare C-suite executives in advance about potential growth needs so the discussion does not feel like a surprise.
• Know your market. Don’t wait until a new active-adult community floods the hospital with patients to begin analyzing the impact new residents might have. The same goes for companies that are bringing thousands of new workers to an area.
• Prepare to do nothing. Too often, group leaders think the easiest solution is hiring a physician to lessen workload. Instead, exhaust improved efficiency options and infrastructure improvements that could accomplish the same goal.

“There is no one specific measure,” says Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member. “You have to look at it from several different aspects, and all or most need to line up and say that, yes, you could use more help.”

Practice Analysis

Dr. Kealey, board liaison to SHM’s Practice Analysis Committee, says that benchmarking might be among the most important first steps in determining the right time to grow a practice. Group leaders should keep in mind, though, that comparative analysis to outside measures is only step one of gauging a group’s performance.

“The external benchmarking is easy,” he says. “You can look at SHM survey data. There are a lot of places that will do local market surveys; that’s easy stuff to look at. It’s the internal stuff that’s a bit harder to make the case for, ‘OK, yes, I am a little below the national benchmarks, but here’s why.’”

Dr. Kealey

In those instances, group leaders need to “look at the value equation” and engage hospital administrators in a discussion on why such metrics as wRVUs and ADC might not match local, regional, or national standards. Perhaps a hospital has a lower payor mix than the sample pool, or comparable regional institutions have a better mix of medical and surgical comanagement populations. Regardless of the details of the tailored explanation, the conversation must be one that’s ongoing between a group leader and the C-suite or it is likely to fail, Dr. Kealey says.

“It really gets to the partnership between the hospital and the hospitalist group and working together throughout the whole year, and not just looking at staffing needs, but looking at the hospital’s quality,” he adds. “It’s looking at [the hospital’s] ability to retain the surgeons and the specialists. It’s the leadership that you’re providing. It’s showing that you’re a real partner, so that when it does come time to make that value argument, that we need to grow...there is buy-in.

“If you’re not a true partner and you just come in as an adversary, I think your odds of success are not very high.”

Dr. Sloan

Steve Sloan, MD, a partner at AIM Hospitalist Group of Westmont, Ill., says that group leaders would be wise to obtain input from all of their physicians before adding a new doctor, as each new hire impacts compensation for existing staff members. In Dr. Sloan’s 16-member group, 11 physicians are partners who discuss growth plans. The other doctors are on partnership tracks. And while that makes discussions more difficult than when nine physicians formed the group in 2007, up-front dialogue is crucial, Dr. Sloan says.

“We try to get all the partners together to make major decisions, such as hiring,” he says. “We don’t need everyone involved in every decision, but it’s not just one or two people making the decision.”

The conversation about growth also differs if new hires are needed to move the group into a new business line or if the group is adding staff to deal with its current patient load. Both require a business case for expansion to be made, but either way, codifying expectations with hospital clients is another way to streamline the growth process, says Dr. Alhadeff. His group contracts with his hospital to provide services and has the ability to autonomously add or delete staff as needed. Although personnel moves don’t require prior approval from the hospital, there is “an expected fiscal responsibility on our end and predetermined agreement do so.”

The group also keeps administrative stakeholders updated to make sure everyone is on the same page. Other groups might delineate in a contract what thresholds need to be met for expansion to be viable.

“It needs to be agreed upon,” Dr. Alhadeff says. “I like the flexibility of being able to determine within our company what we’re doing. But in answer to that, there are unintentional consequences. If we determine that we’re going to bring on someone else, and then we see after a few months that there is not enough volume to support this new physician, we could run into a problem. We will then have to make a financial decision, and the worst thing is to have to fire someone.”

Dr. Alhadeff also worries about the flipside: failing to hire when staff is overworked.

“We run that risk also,” he says. “We are walking a tightrope all the time, and we need to balance that tightrope.”

When you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on. [Group leaders] need to understand the importance of [long-term analysis] and how all the pieces tie in together.

—Kenneth Hertz, FACMPE, principal, Medical Group Management Association Health Care Consulting Group, Denver

The Long View

Another tightrope is timing. Kenneth Hertz, FACMPE, principal of the Medical Group Management Association’s Health Care Consulting Group, says that it can take six months or longer to hire a physician, which means group leaders need to have a continual focus on whether growth is needed or will soon be needed. He suggests forecasting at least 12 to 18 months in advance to stay ahead of staffing needs.

Unfortunately, he says, analysis often gets put on hold in the shuffle of dealing with daily duties. “This is kind of generic to practice administrators, who are putting out fires almost every day. And when you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on,” he says. “They need to understand the importance of it and how all the pieces tie in together.”

Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va., says an important approach is to realize growth isn’t always a good thing. HM group leaders often want to grow before they have stabilized their existing business lines, he says, and that can be the worst tack to take. He also notes that a group leader should ingratiate their program into the fabric of their hospital and not just rely on data to make the argument of the group’s value. That means putting hospitalists on committees, spearheading safety programs, and being seen as a partner in the institution.

“Job One is always patient safety and physician sanity,” he says. “If you are careful about growth and buy-in, and you do the committee work and support everybody so that you’re firmly entrenched in the hospital as a value, it’s much safer to grow. Growing for the sake of growing, you risk overexpansion, and that’s dangerous.”

Many hospitalist groups looking to grow will use locum tenens to bridge the staffing gap while they hire new employees (see “No Strings Attached,” December 2012, p. 36), but Dr. Hazen says without a longer view, that only serves as a Band-Aid.

Hertz, the consultant, often uses an analogy to show how important it is to be constantly planning ahead of the growth curve.

“It is a little bit like building roads,” he says. “Once you decide you need to add two lanes, by the time those are finished, you realize we really need to add two more lanes.”

Richard Quinn is a freelance writer in New Jersey.

Ilan Alhadeff, MD, SFHM, program medical director for Cogent HMG at Hackensack University Medical Center in Hackensack, N.J., pays a lot of attention to the work relative-value units (wRVUs) his hospitalists are producing and the number of encounters they’re tallying. But he’s not particularly worried about what he sees on a daily, weekly, or even monthly basis; he takes a monthslong view of his data when he wants to forecast whether he is going to need to think about adding staff.

“When you look at months, you can start seeing trends,” Dr. Alhadeff says. “Let’s say there’s 16 to 18 average encounters. If your average is 16, you’re saying, ‘OK, you’re on the lower end of your normal.’ And if your average is 18, you’re on the higher end of normal. But if you start seeing 18 every month, odds are you’re going to start getting to 19. So at that point, that’s raising the thought that we need to start thinking about bringing someone else on.”

Dr. Alhadeff

It’s a dance HM group leaders around the country have to do when confronted with the age-old question: Should we expand our service? The answer is more art than science, experts say, as there is no standardized formula for knowing when your HM group should request more support from administration to add an FTE—or two or three. And, in a nod to the HM adage that if you’ve seen one HM group (HMG), then you’ve seen one HMG, the roadmap to expansion varies from place to place. But in a series of interviews with The Hospitalist, physicians, consultants, and management experts suggest there are broad themes that guide the process, including:

• Data. Dashboard metrics, such as average daily census (ADC), wRVUs, patient encounters, and length of stay (LOS), must be quantified. No discussion on expansion can be intelligibly made without a firm understanding of where a practice currently stands.
• Benchmarking. Collating figures isn’t enough. Measure your group against other local HMGs, regional groups, and national standards. SHM’s 2012 State of Hospital Medicine report is a good place to start.
• Scope or schedule. Pushing into new business lines (e.g. orthopedic comanagement) often requires new staff, as does adding shifts to provide 24-hour on-site coverage. Those arguments are different from the case to be made for expanding based on increased patient encounters.
• Physician buy-in. Group leaders cannot unilaterally determine it’s time to add staff, particularly in small-group settings in which hiring a new physician means taking revenue away from the existing group, if only in the short term. Talk with group members before embarking on expansion. Keep track of physician turnover. If hospitalists are leaving often, it could be a sign the group is understaffed.
• Administrative buy-in. If a group leader’s request for a new hire comes without months of conversation ahead of it, it’s likely too late. Prepare C-suite executives in advance about potential growth needs so the discussion does not feel like a surprise.
• Know your market. Don’t wait until a new active-adult community floods the hospital with patients to begin analyzing the impact new residents might have. The same goes for companies that are bringing thousands of new workers to an area.
• Prepare to do nothing. Too often, group leaders think the easiest solution is hiring a physician to lessen workload. Instead, exhaust improved efficiency options and infrastructure improvements that could accomplish the same goal.

“There is no one specific measure,” says Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member. “You have to look at it from several different aspects, and all or most need to line up and say that, yes, you could use more help.”

Practice Analysis

Dr. Kealey, board liaison to SHM’s Practice Analysis Committee, says that benchmarking might be among the most important first steps in determining the right time to grow a practice. Group leaders should keep in mind, though, that comparative analysis to outside measures is only step one of gauging a group’s performance.

“The external benchmarking is easy,” he says. “You can look at SHM survey data. There are a lot of places that will do local market surveys; that’s easy stuff to look at. It’s the internal stuff that’s a bit harder to make the case for, ‘OK, yes, I am a little below the national benchmarks, but here’s why.’”

Dr. Kealey

In those instances, group leaders need to “look at the value equation” and engage hospital administrators in a discussion on why such metrics as wRVUs and ADC might not match local, regional, or national standards. Perhaps a hospital has a lower payor mix than the sample pool, or comparable regional institutions have a better mix of medical and surgical comanagement populations. Regardless of the details of the tailored explanation, the conversation must be one that’s ongoing between a group leader and the C-suite or it is likely to fail, Dr. Kealey says.

“It really gets to the partnership between the hospital and the hospitalist group and working together throughout the whole year, and not just looking at staffing needs, but looking at the hospital’s quality,” he adds. “It’s looking at [the hospital’s] ability to retain the surgeons and the specialists. It’s the leadership that you’re providing. It’s showing that you’re a real partner, so that when it does come time to make that value argument, that we need to grow...there is buy-in.

“If you’re not a true partner and you just come in as an adversary, I think your odds of success are not very high.”

Dr. Sloan

Steve Sloan, MD, a partner at AIM Hospitalist Group of Westmont, Ill., says that group leaders would be wise to obtain input from all of their physicians before adding a new doctor, as each new hire impacts compensation for existing staff members. In Dr. Sloan’s 16-member group, 11 physicians are partners who discuss growth plans. The other doctors are on partnership tracks. And while that makes discussions more difficult than when nine physicians formed the group in 2007, up-front dialogue is crucial, Dr. Sloan says.

“We try to get all the partners together to make major decisions, such as hiring,” he says. “We don’t need everyone involved in every decision, but it’s not just one or two people making the decision.”

The conversation about growth also differs if new hires are needed to move the group into a new business line or if the group is adding staff to deal with its current patient load. Both require a business case for expansion to be made, but either way, codifying expectations with hospital clients is another way to streamline the growth process, says Dr. Alhadeff. His group contracts with his hospital to provide services and has the ability to autonomously add or delete staff as needed. Although personnel moves don’t require prior approval from the hospital, there is “an expected fiscal responsibility on our end and predetermined agreement do so.”

The group also keeps administrative stakeholders updated to make sure everyone is on the same page. Other groups might delineate in a contract what thresholds need to be met for expansion to be viable.

“It needs to be agreed upon,” Dr. Alhadeff says. “I like the flexibility of being able to determine within our company what we’re doing. But in answer to that, there are unintentional consequences. If we determine that we’re going to bring on someone else, and then we see after a few months that there is not enough volume to support this new physician, we could run into a problem. We will then have to make a financial decision, and the worst thing is to have to fire someone.”

Dr. Alhadeff also worries about the flipside: failing to hire when staff is overworked.

“We run that risk also,” he says. “We are walking a tightrope all the time, and we need to balance that tightrope.”

When you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on. [Group leaders] need to understand the importance of [long-term analysis] and how all the pieces tie in together.

—Kenneth Hertz, FACMPE, principal, Medical Group Management Association Health Care Consulting Group, Denver

The Long View

Another tightrope is timing. Kenneth Hertz, FACMPE, principal of the Medical Group Management Association’s Health Care Consulting Group, says that it can take six months or longer to hire a physician, which means group leaders need to have a continual focus on whether growth is needed or will soon be needed. He suggests forecasting at least 12 to 18 months in advance to stay ahead of staffing needs.

Unfortunately, he says, analysis often gets put on hold in the shuffle of dealing with daily duties. “This is kind of generic to practice administrators, who are putting out fires almost every day. And when you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on,” he says. “They need to understand the importance of it and how all the pieces tie in together.”

Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va., says an important approach is to realize growth isn’t always a good thing. HM group leaders often want to grow before they have stabilized their existing business lines, he says, and that can be the worst tack to take. He also notes that a group leader should ingratiate their program into the fabric of their hospital and not just rely on data to make the argument of the group’s value. That means putting hospitalists on committees, spearheading safety programs, and being seen as a partner in the institution.

“Job One is always patient safety and physician sanity,” he says. “If you are careful about growth and buy-in, and you do the committee work and support everybody so that you’re firmly entrenched in the hospital as a value, it’s much safer to grow. Growing for the sake of growing, you risk overexpansion, and that’s dangerous.”

Many hospitalist groups looking to grow will use locum tenens to bridge the staffing gap while they hire new employees (see “No Strings Attached,” December 2012, p. 36), but Dr. Hazen says without a longer view, that only serves as a Band-Aid.

Hertz, the consultant, often uses an analogy to show how important it is to be constantly planning ahead of the growth curve.

“It is a little bit like building roads,” he says. “Once you decide you need to add two lanes, by the time those are finished, you realize we really need to add two more lanes.”

Richard Quinn is a freelance writer in New Jersey.

Ilan Alhadeff, MD, SFHM, program medical director for Cogent HMG at Hackensack University Medical Center in Hackensack, N.J., pays a lot of attention to the work relative-value units (wRVUs) his hospitalists are producing and the number of encounters they’re tallying. But he’s not particularly worried about what he sees on a daily, weekly, or even monthly basis; he takes a monthslong view of his data when he wants to forecast whether he is going to need to think about adding staff.

“When you look at months, you can start seeing trends,” Dr. Alhadeff says. “Let’s say there’s 16 to 18 average encounters. If your average is 16, you’re saying, ‘OK, you’re on the lower end of your normal.’ And if your average is 18, you’re on the higher end of normal. But if you start seeing 18 every month, odds are you’re going to start getting to 19. So at that point, that’s raising the thought that we need to start thinking about bringing someone else on.”

Dr. Alhadeff

It’s a dance HM group leaders around the country have to do when confronted with the age-old question: Should we expand our service? The answer is more art than science, experts say, as there is no standardized formula for knowing when your HM group should request more support from administration to add an FTE—or two or three. And, in a nod to the HM adage that if you’ve seen one HM group (HMG), then you’ve seen one HMG, the roadmap to expansion varies from place to place. But in a series of interviews with The Hospitalist, physicians, consultants, and management experts suggest there are broad themes that guide the process, including:

• Data. Dashboard metrics, such as average daily census (ADC), wRVUs, patient encounters, and length of stay (LOS), must be quantified. No discussion on expansion can be intelligibly made without a firm understanding of where a practice currently stands.
• Benchmarking. Collating figures isn’t enough. Measure your group against other local HMGs, regional groups, and national standards. SHM’s 2012 State of Hospital Medicine report is a good place to start.
• Scope or schedule. Pushing into new business lines (e.g. orthopedic comanagement) often requires new staff, as does adding shifts to provide 24-hour on-site coverage. Those arguments are different from the case to be made for expanding based on increased patient encounters.
• Physician buy-in. Group leaders cannot unilaterally determine it’s time to add staff, particularly in small-group settings in which hiring a new physician means taking revenue away from the existing group, if only in the short term. Talk with group members before embarking on expansion. Keep track of physician turnover. If hospitalists are leaving often, it could be a sign the group is understaffed.
• Administrative buy-in. If a group leader’s request for a new hire comes without months of conversation ahead of it, it’s likely too late. Prepare C-suite executives in advance about potential growth needs so the discussion does not feel like a surprise.
• Know your market. Don’t wait until a new active-adult community floods the hospital with patients to begin analyzing the impact new residents might have. The same goes for companies that are bringing thousands of new workers to an area.
• Prepare to do nothing. Too often, group leaders think the easiest solution is hiring a physician to lessen workload. Instead, exhaust improved efficiency options and infrastructure improvements that could accomplish the same goal.

“There is no one specific measure,” says Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member. “You have to look at it from several different aspects, and all or most need to line up and say that, yes, you could use more help.”

Practice Analysis

Dr. Kealey, board liaison to SHM’s Practice Analysis Committee, says that benchmarking might be among the most important first steps in determining the right time to grow a practice. Group leaders should keep in mind, though, that comparative analysis to outside measures is only step one of gauging a group’s performance.

“The external benchmarking is easy,” he says. “You can look at SHM survey data. There are a lot of places that will do local market surveys; that’s easy stuff to look at. It’s the internal stuff that’s a bit harder to make the case for, ‘OK, yes, I am a little below the national benchmarks, but here’s why.’”

Dr. Kealey

In those instances, group leaders need to “look at the value equation” and engage hospital administrators in a discussion on why such metrics as wRVUs and ADC might not match local, regional, or national standards. Perhaps a hospital has a lower payor mix than the sample pool, or comparable regional institutions have a better mix of medical and surgical comanagement populations. Regardless of the details of the tailored explanation, the conversation must be one that’s ongoing between a group leader and the C-suite or it is likely to fail, Dr. Kealey says.

“It really gets to the partnership between the hospital and the hospitalist group and working together throughout the whole year, and not just looking at staffing needs, but looking at the hospital’s quality,” he adds. “It’s looking at [the hospital’s] ability to retain the surgeons and the specialists. It’s the leadership that you’re providing. It’s showing that you’re a real partner, so that when it does come time to make that value argument, that we need to grow...there is buy-in.

“If you’re not a true partner and you just come in as an adversary, I think your odds of success are not very high.”

Dr. Sloan

Steve Sloan, MD, a partner at AIM Hospitalist Group of Westmont, Ill., says that group leaders would be wise to obtain input from all of their physicians before adding a new doctor, as each new hire impacts compensation for existing staff members. In Dr. Sloan’s 16-member group, 11 physicians are partners who discuss growth plans. The other doctors are on partnership tracks. And while that makes discussions more difficult than when nine physicians formed the group in 2007, up-front dialogue is crucial, Dr. Sloan says.

“We try to get all the partners together to make major decisions, such as hiring,” he says. “We don’t need everyone involved in every decision, but it’s not just one or two people making the decision.”

The conversation about growth also differs if new hires are needed to move the group into a new business line or if the group is adding staff to deal with its current patient load. Both require a business case for expansion to be made, but either way, codifying expectations with hospital clients is another way to streamline the growth process, says Dr. Alhadeff. His group contracts with his hospital to provide services and has the ability to autonomously add or delete staff as needed. Although personnel moves don’t require prior approval from the hospital, there is “an expected fiscal responsibility on our end and predetermined agreement do so.”

The group also keeps administrative stakeholders updated to make sure everyone is on the same page. Other groups might delineate in a contract what thresholds need to be met for expansion to be viable.

“It needs to be agreed upon,” Dr. Alhadeff says. “I like the flexibility of being able to determine within our company what we’re doing. But in answer to that, there are unintentional consequences. If we determine that we’re going to bring on someone else, and then we see after a few months that there is not enough volume to support this new physician, we could run into a problem. We will then have to make a financial decision, and the worst thing is to have to fire someone.”

Dr. Alhadeff also worries about the flipside: failing to hire when staff is overworked.

“We run that risk also,” he says. “We are walking a tightrope all the time, and we need to balance that tightrope.”

When you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on. [Group leaders] need to understand the importance of [long-term analysis] and how all the pieces tie in together.

—Kenneth Hertz, FACMPE, principal, Medical Group Management Association Health Care Consulting Group, Denver

The Long View

Another tightrope is timing. Kenneth Hertz, FACMPE, principal of the Medical Group Management Association’s Health Care Consulting Group, says that it can take six months or longer to hire a physician, which means group leaders need to have a continual focus on whether growth is needed or will soon be needed. He suggests forecasting at least 12 to 18 months in advance to stay ahead of staffing needs.

Unfortunately, he says, analysis often gets put on hold in the shuffle of dealing with daily duties. “This is kind of generic to practice administrators, who are putting out fires almost every day. And when you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on,” he says. “They need to understand the importance of it and how all the pieces tie in together.”

Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va., says an important approach is to realize growth isn’t always a good thing. HM group leaders often want to grow before they have stabilized their existing business lines, he says, and that can be the worst tack to take. He also notes that a group leader should ingratiate their program into the fabric of their hospital and not just rely on data to make the argument of the group’s value. That means putting hospitalists on committees, spearheading safety programs, and being seen as a partner in the institution.

“Job One is always patient safety and physician sanity,” he says. “If you are careful about growth and buy-in, and you do the committee work and support everybody so that you’re firmly entrenched in the hospital as a value, it’s much safer to grow. Growing for the sake of growing, you risk overexpansion, and that’s dangerous.”

Many hospitalist groups looking to grow will use locum tenens to bridge the staffing gap while they hire new employees (see “No Strings Attached,” December 2012, p. 36), but Dr. Hazen says without a longer view, that only serves as a Band-Aid.

Hertz, the consultant, often uses an analogy to show how important it is to be constantly planning ahead of the growth curve.

“It is a little bit like building roads,” he says. “Once you decide you need to add two lanes, by the time those are finished, you realize we really need to add two more lanes.”

Richard Quinn is a freelance writer in New Jersey.

Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.

Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.

Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.

Data from Malpractice Insurers

I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.

The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”

I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.

Why Is Epidural Abscess a High Risk?

There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.

Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.

One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.

Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)

Practice Management Perspective

I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.

Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.

Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.

Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.

Data from Malpractice Insurers

I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.

The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”

I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.

Why Is Epidural Abscess a High Risk?

There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.

Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.

One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.

Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)

Practice Management Perspective

I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.

Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.

Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.

Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.

Data from Malpractice Insurers

I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.

The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”

I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.

Why Is Epidural Abscess a High Risk?

There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.

Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.

One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.

Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)

Practice Management Perspective

I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.

Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Click here to listen to Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va.

Click here to listen to Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va.

Click here to listen to Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va.

When it comes to Medicare, the Affordable Care Act, and a host of other healthcare-reform-related topics, hospitalists have lots of good questions, such as:

• When does the Physician Value-Based Payment Modifier (VBPM) take effect? And will I be included?
• Which primary-care services are covered by the increased Medicaid payments?
• Are hospitalists eligible to bill for Medicare’s new CPT Transitional Care Management (TCM) codes? (see “New Codes Bridge Billing Gap,”).

Now, SHM’s Public Policy Committee has answered all of the above—and many more—in a set of three “Frequently Asked Questions” documents available at www.hospitalmedicine.org/advocacy. Each document goes in-depth on the most cutting-edge policy issues that are top of mind for hospitalists and the hospitals they serve on these issues:

The Physician Value-Based Payment Modifier (VBPM): The VBPM seeks to connect cost and quality of services in order to begin reimbursement for the value, rather than the quantity, of care. It combines the quality measuring in the Physician Quality Reporting System (PQRS), cost measures, and a payment adjustment for physicians. Measurement begins this year, and many hospitalists will be included.

Medicaid/Medicare parity regulation: On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulations implementing Section 1202 of the Affordable Care Act, which increases Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

New CPT Transitional Care Management (TCM) codes 99495-99496: CMS has created two new CPT Transitional Care Management (TCM) codes designed to improve care coordination and provide better incentives to ensure patients are seen in a physician’s office, rather than be at risk for readmission.

New Action: Getting Involved Just Got Easier

SHM’s Legislative Action Center also makes getting involved easier with a new grassroots outreach tool called Voter Voice. SHM’s first action alert on Voter Voice was sent to members in December. Hospitalists’ willingness to take a few minutes and contact their congressional leaders using Voter Voice increased SHM’s visibility to Congress by nearly five times compared with prior similar alerts.

Getting involved is easy and only takes a few seconds. You can use either your ZIP code to look up your members of Congress or search active legislation by keyword. SHM members can sign up for SHM Legislative Action Center alerts by entering their email address.

To download the new SHM advocacy FAQs or use the improved Legislative Action Center, visit www.hospitalmedicine.org/advocacy.

When it comes to Medicare, the Affordable Care Act, and a host of other healthcare-reform-related topics, hospitalists have lots of good questions, such as:

• When does the Physician Value-Based Payment Modifier (VBPM) take effect? And will I be included?
• Which primary-care services are covered by the increased Medicaid payments?
• Are hospitalists eligible to bill for Medicare’s new CPT Transitional Care Management (TCM) codes? (see “New Codes Bridge Billing Gap,”).

Now, SHM’s Public Policy Committee has answered all of the above—and many more—in a set of three “Frequently Asked Questions” documents available at www.hospitalmedicine.org/advocacy. Each document goes in-depth on the most cutting-edge policy issues that are top of mind for hospitalists and the hospitals they serve on these issues:

The Physician Value-Based Payment Modifier (VBPM): The VBPM seeks to connect cost and quality of services in order to begin reimbursement for the value, rather than the quantity, of care. It combines the quality measuring in the Physician Quality Reporting System (PQRS), cost measures, and a payment adjustment for physicians. Measurement begins this year, and many hospitalists will be included.

Medicaid/Medicare parity regulation: On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulations implementing Section 1202 of the Affordable Care Act, which increases Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

New CPT Transitional Care Management (TCM) codes 99495-99496: CMS has created two new CPT Transitional Care Management (TCM) codes designed to improve care coordination and provide better incentives to ensure patients are seen in a physician’s office, rather than be at risk for readmission.

New Action: Getting Involved Just Got Easier

SHM’s Legislative Action Center also makes getting involved easier with a new grassroots outreach tool called Voter Voice. SHM’s first action alert on Voter Voice was sent to members in December. Hospitalists’ willingness to take a few minutes and contact their congressional leaders using Voter Voice increased SHM’s visibility to Congress by nearly five times compared with prior similar alerts.

Getting involved is easy and only takes a few seconds. You can use either your ZIP code to look up your members of Congress or search active legislation by keyword. SHM members can sign up for SHM Legislative Action Center alerts by entering their email address.

To download the new SHM advocacy FAQs or use the improved Legislative Action Center, visit www.hospitalmedicine.org/advocacy.

When it comes to Medicare, the Affordable Care Act, and a host of other healthcare-reform-related topics, hospitalists have lots of good questions, such as:

• When does the Physician Value-Based Payment Modifier (VBPM) take effect? And will I be included?
• Which primary-care services are covered by the increased Medicaid payments?
• Are hospitalists eligible to bill for Medicare’s new CPT Transitional Care Management (TCM) codes? (see “New Codes Bridge Billing Gap,”).

Now, SHM’s Public Policy Committee has answered all of the above—and many more—in a set of three “Frequently Asked Questions” documents available at www.hospitalmedicine.org/advocacy. Each document goes in-depth on the most cutting-edge policy issues that are top of mind for hospitalists and the hospitals they serve on these issues:

The Physician Value-Based Payment Modifier (VBPM): The VBPM seeks to connect cost and quality of services in order to begin reimbursement for the value, rather than the quantity, of care. It combines the quality measuring in the Physician Quality Reporting System (PQRS), cost measures, and a payment adjustment for physicians. Measurement begins this year, and many hospitalists will be included.

Medicaid/Medicare parity regulation: On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulations implementing Section 1202 of the Affordable Care Act, which increases Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

New CPT Transitional Care Management (TCM) codes 99495-99496: CMS has created two new CPT Transitional Care Management (TCM) codes designed to improve care coordination and provide better incentives to ensure patients are seen in a physician’s office, rather than be at risk for readmission.

New Action: Getting Involved Just Got Easier

SHM’s Legislative Action Center also makes getting involved easier with a new grassroots outreach tool called Voter Voice. SHM’s first action alert on Voter Voice was sent to members in December. Hospitalists’ willingness to take a few minutes and contact their congressional leaders using Voter Voice increased SHM’s visibility to Congress by nearly five times compared with prior similar alerts.

Getting involved is easy and only takes a few seconds. You can use either your ZIP code to look up your members of Congress or search active legislation by keyword. SHM members can sign up for SHM Legislative Action Center alerts by entering their email address.

To download the new SHM advocacy FAQs or use the improved Legislative Action Center, visit www.hospitalmedicine.org/advocacy.

Although pediatricians make up less than 6% of the hospitalists surveyed by the Medical Group Management Association (MGMA), they represent a very different data profile from other specialties reported in SHM’s 2012 State of Hospital Medicine report.

The nonpediatric HM specialties (internal medicine, family medicine, and med/peds) have similar data profiles with regard to productivity and compensation statistics. They are all within 2% of the $233,855 “all adult hospitalists” median compensation. Although there is a bit more variability in the productivity data, all three groups are clustered within 10% of each other. The key to understanding their similarity is that they all serve mostly adult inpatients. While some of these physicians may also care for hospitalized children, I suspect this population is a small proportion of their daily workload.

Pediatric hospitalists only treat pediatric patients and differ significantly from adult hospitalists, as summarized in Table 1.

click for large version

Pediatricians remain among the lowest-earning specialties nationally, whether in the office or on children’s wards. The key to understanding the differences between adult and pediatric hospitalists is that they derive their compensation and productivity expectations from two separate and distinct physician marketplaces. Adult hospitalists benefit from more than a decade of rapidly growing demand for their services, as well as higher compensation for their office-based counterparts. Meanwhile, the market for pediatric hospitalists remains smaller and more segmented, allowing local factors to drive compensation more than a national demand for their services would.

Dr. Ahlstrom

Pediatric hospitalists appear to earn about a quarter less than their adult counterparts while receiving a similarly lower amount of hospital financial support per provider. Pediatric hospitalists also appear to work less than adult hospitalists, reflected in fewer shifts annually and fewer hours per shift; 75% of adult hospitalist groups report shift lengths of 12 hours or more, compared with 48% of pediatric hospitalist groups. This may stem from the frequent lulls in census common to a community hospital pediatrics service, in contrast to more consistent demand posed by geriatric populations. Although pediatric hospitalists receive more compensation per encounter or wRVU, they cannot generate those encounters or work RVUs at the same clip as adult hospitalists. Pediatricians must hold a family meeting for every single patient, and even something as seemingly simple as obtaining intravenous access might consume 45 minutes of a hospitalist’s time.

Thus, pediatric hospitalists find themselves caught in the same market as other pediatric specialists. These providers remain undervalued compared to virtually all other physicians. Those who seek to improve their financial prospects likely need to work more shifts or generate more workload relative to the expectations of their pediatrician peers.

Personally, I can’t help but wonder what attention pediatric care might enjoy if kids had a vote, a pension, an entitlement program, and a lobby on K Street like their grandparents do.

Dr. Ahlstrom is clinical director of Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis Committee.

Although pediatricians make up less than 6% of the hospitalists surveyed by the Medical Group Management Association (MGMA), they represent a very different data profile from other specialties reported in SHM’s 2012 State of Hospital Medicine report.

The nonpediatric HM specialties (internal medicine, family medicine, and med/peds) have similar data profiles with regard to productivity and compensation statistics. They are all within 2% of the $233,855 “all adult hospitalists” median compensation. Although there is a bit more variability in the productivity data, all three groups are clustered within 10% of each other. The key to understanding their similarity is that they all serve mostly adult inpatients. While some of these physicians may also care for hospitalized children, I suspect this population is a small proportion of their daily workload.

Pediatric hospitalists only treat pediatric patients and differ significantly from adult hospitalists, as summarized in Table 1.

click for large version

Pediatricians remain among the lowest-earning specialties nationally, whether in the office or on children’s wards. The key to understanding the differences between adult and pediatric hospitalists is that they derive their compensation and productivity expectations from two separate and distinct physician marketplaces. Adult hospitalists benefit from more than a decade of rapidly growing demand for their services, as well as higher compensation for their office-based counterparts. Meanwhile, the market for pediatric hospitalists remains smaller and more segmented, allowing local factors to drive compensation more than a national demand for their services would.

Dr. Ahlstrom

Pediatric hospitalists appear to earn about a quarter less than their adult counterparts while receiving a similarly lower amount of hospital financial support per provider. Pediatric hospitalists also appear to work less than adult hospitalists, reflected in fewer shifts annually and fewer hours per shift; 75% of adult hospitalist groups report shift lengths of 12 hours or more, compared with 48% of pediatric hospitalist groups. This may stem from the frequent lulls in census common to a community hospital pediatrics service, in contrast to more consistent demand posed by geriatric populations. Although pediatric hospitalists receive more compensation per encounter or wRVU, they cannot generate those encounters or work RVUs at the same clip as adult hospitalists. Pediatricians must hold a family meeting for every single patient, and even something as seemingly simple as obtaining intravenous access might consume 45 minutes of a hospitalist’s time.

Thus, pediatric hospitalists find themselves caught in the same market as other pediatric specialists. These providers remain undervalued compared to virtually all other physicians. Those who seek to improve their financial prospects likely need to work more shifts or generate more workload relative to the expectations of their pediatrician peers.

Personally, I can’t help but wonder what attention pediatric care might enjoy if kids had a vote, a pension, an entitlement program, and a lobby on K Street like their grandparents do.

Dr. Ahlstrom is clinical director of Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis Committee.

Although pediatricians make up less than 6% of the hospitalists surveyed by the Medical Group Management Association (MGMA), they represent a very different data profile from other specialties reported in SHM’s 2012 State of Hospital Medicine report.

The nonpediatric HM specialties (internal medicine, family medicine, and med/peds) have similar data profiles with regard to productivity and compensation statistics. They are all within 2% of the $233,855 “all adult hospitalists” median compensation. Although there is a bit more variability in the productivity data, all three groups are clustered within 10% of each other. The key to understanding their similarity is that they all serve mostly adult inpatients. While some of these physicians may also care for hospitalized children, I suspect this population is a small proportion of their daily workload.

Pediatric hospitalists only treat pediatric patients and differ significantly from adult hospitalists, as summarized in Table 1.

click for large version

Pediatricians remain among the lowest-earning specialties nationally, whether in the office or on children’s wards. The key to understanding the differences between adult and pediatric hospitalists is that they derive their compensation and productivity expectations from two separate and distinct physician marketplaces. Adult hospitalists benefit from more than a decade of rapidly growing demand for their services, as well as higher compensation for their office-based counterparts. Meanwhile, the market for pediatric hospitalists remains smaller and more segmented, allowing local factors to drive compensation more than a national demand for their services would.

Dr. Ahlstrom

Pediatric hospitalists appear to earn about a quarter less than their adult counterparts while receiving a similarly lower amount of hospital financial support per provider. Pediatric hospitalists also appear to work less than adult hospitalists, reflected in fewer shifts annually and fewer hours per shift; 75% of adult hospitalist groups report shift lengths of 12 hours or more, compared with 48% of pediatric hospitalist groups. This may stem from the frequent lulls in census common to a community hospital pediatrics service, in contrast to more consistent demand posed by geriatric populations. Although pediatric hospitalists receive more compensation per encounter or wRVU, they cannot generate those encounters or work RVUs at the same clip as adult hospitalists. Pediatricians must hold a family meeting for every single patient, and even something as seemingly simple as obtaining intravenous access might consume 45 minutes of a hospitalist’s time.

Thus, pediatric hospitalists find themselves caught in the same market as other pediatric specialists. These providers remain undervalued compared to virtually all other physicians. Those who seek to improve their financial prospects likely need to work more shifts or generate more workload relative to the expectations of their pediatrician peers.

Personally, I can’t help but wonder what attention pediatric care might enjoy if kids had a vote, a pension, an entitlement program, and a lobby on K Street like their grandparents do.

Dr. Ahlstrom is clinical director of Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis Committee.

This month, hospitalists will be a vital part of Choosing Wisely, an important public initiative from the American Board of Internal Medicine (ABIM) Foundation that identifies treatments and procedures that might be overused by caregivers.

On Feb. 21 in Washington, D.C., the ABIM Foundation, SHM, and more than a dozen other medical specialties will announce recommendations that, in the ABIM Foundation’s words, “represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” Hospitalists who helped SHM develop its recommendations will be in attendance to help field questions about SHM’s work with Choosing Wisely and its lists.

SHM has developed two lists of recommendations: one for adult HM and another for pediatric HM. SHM will make a special announcement Feb. 21 in The Hospitalist eWire with both lists and commentary for how hospitalists can have informed conversations with their patients about the lists. The Hospitalist will follow up with a feature story and other information about Choosing Wisely in its March issue.

As part of the campaign, the ABIM Foundation, SHM, and consumer magazine Consumer Reports have teamed up to develop material specifically designed to educate patients about the Choosing Wisely recommendations. Materials will be available on the ABIM Foundation and SHM websites.

SHM will continue the conversation about high-value care and working with patients to make wise decisions well beyond February and March. At HM13, SHM’s annual meeting in Washington, D.C., SHM will offer a pre-course on Choosing Wisely and its philosophy. The pre-course is May 16, the day before the official start of HM13.

For more information about Choosing Wisely, visit www.choosingwisely.org. To register for the Choosing Wisely pre-course at HM13, visit www.hospitalmedicine2013.org.

This month, hospitalists will be a vital part of Choosing Wisely, an important public initiative from the American Board of Internal Medicine (ABIM) Foundation that identifies treatments and procedures that might be overused by caregivers.

On Feb. 21 in Washington, D.C., the ABIM Foundation, SHM, and more than a dozen other medical specialties will announce recommendations that, in the ABIM Foundation’s words, “represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” Hospitalists who helped SHM develop its recommendations will be in attendance to help field questions about SHM’s work with Choosing Wisely and its lists.

SHM has developed two lists of recommendations: one for adult HM and another for pediatric HM. SHM will make a special announcement Feb. 21 in The Hospitalist eWire with both lists and commentary for how hospitalists can have informed conversations with their patients about the lists. The Hospitalist will follow up with a feature story and other information about Choosing Wisely in its March issue.

As part of the campaign, the ABIM Foundation, SHM, and consumer magazine Consumer Reports have teamed up to develop material specifically designed to educate patients about the Choosing Wisely recommendations. Materials will be available on the ABIM Foundation and SHM websites.

SHM will continue the conversation about high-value care and working with patients to make wise decisions well beyond February and March. At HM13, SHM’s annual meeting in Washington, D.C., SHM will offer a pre-course on Choosing Wisely and its philosophy. The pre-course is May 16, the day before the official start of HM13.

For more information about Choosing Wisely, visit www.choosingwisely.org. To register for the Choosing Wisely pre-course at HM13, visit www.hospitalmedicine2013.org.

This month, hospitalists will be a vital part of Choosing Wisely, an important public initiative from the American Board of Internal Medicine (ABIM) Foundation that identifies treatments and procedures that might be overused by caregivers.

On Feb. 21 in Washington, D.C., the ABIM Foundation, SHM, and more than a dozen other medical specialties will announce recommendations that, in the ABIM Foundation’s words, “represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” Hospitalists who helped SHM develop its recommendations will be in attendance to help field questions about SHM’s work with Choosing Wisely and its lists.

SHM has developed two lists of recommendations: one for adult HM and another for pediatric HM. SHM will make a special announcement Feb. 21 in The Hospitalist eWire with both lists and commentary for how hospitalists can have informed conversations with their patients about the lists. The Hospitalist will follow up with a feature story and other information about Choosing Wisely in its March issue.

As part of the campaign, the ABIM Foundation, SHM, and consumer magazine Consumer Reports have teamed up to develop material specifically designed to educate patients about the Choosing Wisely recommendations. Materials will be available on the ABIM Foundation and SHM websites.

SHM will continue the conversation about high-value care and working with patients to make wise decisions well beyond February and March. At HM13, SHM’s annual meeting in Washington, D.C., SHM will offer a pre-course on Choosing Wisely and its philosophy. The pre-course is May 16, the day before the official start of HM13.

For more information about Choosing Wisely, visit www.choosingwisely.org. To register for the Choosing Wisely pre-course at HM13, visit www.hospitalmedicine2013.org.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Larry Beresford is a freelance writer in Oakland, Calif.

Articles first published in the Jan. 16, 2013, edition of The Hospitalist eWire.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Larry Beresford is a freelance writer in Oakland, Calif.

Articles first published in the Jan. 16, 2013, edition of The Hospitalist eWire.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Larry Beresford is a freelance writer in Oakland, Calif.

Articles first published in the Jan. 16, 2013, edition of The Hospitalist eWire.

Rajan Gurunathan, MD, was an undergraduate student at Johns Hopkins University in Baltimore in the early 1990s weighing his career options.

“I went through a lot of permutations, actually,” he says. “Scientist, clinical researcher, doctor, physician/scientist—all of those things entered my mind at some point.”

He applied to dual-track MD and PhD programs, but ultimately decided that interacting with people—patients in particular—was the goal for him. He earned his medical degree from UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., and completed his internship in the department of medicine at St. Luke’s-Roosevelt Hospital Center in New York City, not far from where he grew up as a child in northern New Jersey.

And he never left.

I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

Dr. Gurunathan has risen through the ranks at St. Luke’s-Roosevelt, from resident to chief resident to chief of the section of hospital medicine. He is a faculty member for the Clinical Quality Fellowship Program at the Great New York Hospital Association and an assistant clinical professor of medicine at Columbia University College of Physicians and Surgeons in New York.

His long tenure at St. Luke’s-Roosevelt has been “an incredible experience because I really get a sense and feeling of commitment from the community,” he adds. “I’ve seen it grow over time and see how the needs have changed and how the service the hospital has been able to provide has only grown over time.”

After several years of presenting posters at SHM’s annual meetings, Dr. Gurunathan joined Team Hospitalist in April 2012 to become an even more active member of his specialty.

QUESTION: When you started as an intern 15 years ago, did you expect that you’d still be at the same institution?

Answer: No, I wouldn’t have expected that at all. In fact, there was a time where I was briefly considering a general medicine fellowship at Johns Hopkins, and I was prepared to go there. And family circumstances, etc., made me decide not to move on and to make a commitment and join the department as faculty, first as a chief and then as faculty. And I was really lucky to have those opportunities, because while my course didn’t go exactly the way that I’d planned, I wouldn’t have changed a thing.

Q: When you now deal with the residents and younger staff members, what’s that experience like for you?

A: It’s a really neat experience, and often brings a chuckle to my face when I see that they’re frustrated about the same things, because I can certainly commiserate. But I can really also see the value of what they provide every day, and having been in their shoes, I know a little bit about what they’ve been through and the work that they do. So I have a real appreciation for that.

Q: What brought you to hospital medicine?

A: I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

Q: Is there something specific about the setting that’s kept you in the academic world?

A: A lot of things, actually. As I mentioned, hospitals in general should have a collegial nature. Again, it’s a really nice place where people share a unique common goal of banding together and fighting a goal, and academic departments are the same. So it’s being with people with like-minded intellectual interests. And we’re fortunate enough to have a number of strong mentors within the department who have had a lot of clinical training and bring a lot of experience and a wealth of knowledge, and being able to utilize their experience and draw from their experiences only makes people better clinicians. And we’re fortunate enough to have a pretty supportive department in general where there is a lot of collegiality and camaraderie.

Q: As an administrator, what is the value of being an SHM member, to you?

A: I think what I’ve seen administratively is the changing face of healthcare and how hospitals are going to need to continue to transform with time due to things that are both regulatory- and quality-of-care-based, in terms of improving outcomes and keeping people healthy. SHM has really embraced [those changes] and taken them head-on for really important reasons, not only in terms of helping people adapt to the changing landscape, but also training them in the ways that we need to be thinking about problems now and in the future.

Q: You’ve attended multiple annual meetings and presented posters. What value have you taken out of them, and would you recommend the experience to others?

A: Absolutely. I think as people develop, it’s good to always learn new skills, and my clinical research is an area that I would actually like to build up. So I’ve had a little bit of exposure, and it’s been nice to be able to draw from the resources of SHM and be able to partake. We presented something last year, which was a really neat experience, and we’re looking to bring some new faculty this year and encourage them to get involved in the scholarship process. These are the kinds of things that can really help hone skills, and that’s a good thing.

Q: Once you’re inside the doors of a New York City hospital, is daily practice much different than anywhere else?

A: I would say yes and no. I would say no in that I think all hospitals are really neat places and really incredible places. I heard somebody say once at a talk that hospitals were places of refuge, and I really do believe that. That being said, I think there is something slightly unique about New York City in a lot of ways. Certainly the challenges that New York City hospitals face are somewhat unique in terms of patient population, difficulty in socioeconomic factors, insurance issues. I think they are really fun places to work, but they’re not for the faint of heart.

Richard Quinn is a freelance writer in New Jersey.

Rajan Gurunathan, MD, was an undergraduate student at Johns Hopkins University in Baltimore in the early 1990s weighing his career options.

“I went through a lot of permutations, actually,” he says. “Scientist, clinical researcher, doctor, physician/scientist—all of those things entered my mind at some point.”

He applied to dual-track MD and PhD programs, but ultimately decided that interacting with people—patients in particular—was the goal for him. He earned his medical degree from UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., and completed his internship in the department of medicine at St. Luke’s-Roosevelt Hospital Center in New York City, not far from where he grew up as a child in northern New Jersey.

And he never left.

I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

Dr. Gurunathan has risen through the ranks at St. Luke’s-Roosevelt, from resident to chief resident to chief of the section of hospital medicine. He is a faculty member for the Clinical Quality Fellowship Program at the Great New York Hospital Association and an assistant clinical professor of medicine at Columbia University College of Physicians and Surgeons in New York.

His long tenure at St. Luke’s-Roosevelt has been “an incredible experience because I really get a sense and feeling of commitment from the community,” he adds. “I’ve seen it grow over time and see how the needs have changed and how the service the hospital has been able to provide has only grown over time.”

After several years of presenting posters at SHM’s annual meetings, Dr. Gurunathan joined Team Hospitalist in April 2012 to become an even more active member of his specialty.

QUESTION: When you started as an intern 15 years ago, did you expect that you’d still be at the same institution?

Answer: No, I wouldn’t have expected that at all. In fact, there was a time where I was briefly considering a general medicine fellowship at Johns Hopkins, and I was prepared to go there. And family circumstances, etc., made me decide not to move on and to make a commitment and join the department as faculty, first as a chief and then as faculty. And I was really lucky to have those opportunities, because while my course didn’t go exactly the way that I’d planned, I wouldn’t have changed a thing.

Q: When you now deal with the residents and younger staff members, what’s that experience like for you?

A: It’s a really neat experience, and often brings a chuckle to my face when I see that they’re frustrated about the same things, because I can certainly commiserate. But I can really also see the value of what they provide every day, and having been in their shoes, I know a little bit about what they’ve been through and the work that they do. So I have a real appreciation for that.

Q: What brought you to hospital medicine?

A: I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

Q: Is there something specific about the setting that’s kept you in the academic world?

A: A lot of things, actually. As I mentioned, hospitals in general should have a collegial nature. Again, it’s a really nice place where people share a unique common goal of banding together and fighting a goal, and academic departments are the same. So it’s being with people with like-minded intellectual interests. And we’re fortunate enough to have a number of strong mentors within the department who have had a lot of clinical training and bring a lot of experience and a wealth of knowledge, and being able to utilize their experience and draw from their experiences only makes people better clinicians. And we’re fortunate enough to have a pretty supportive department in general where there is a lot of collegiality and camaraderie.

Q: As an administrator, what is the value of being an SHM member, to you?

A: I think what I’ve seen administratively is the changing face of healthcare and how hospitals are going to need to continue to transform with time due to things that are both regulatory- and quality-of-care-based, in terms of improving outcomes and keeping people healthy. SHM has really embraced [those changes] and taken them head-on for really important reasons, not only in terms of helping people adapt to the changing landscape, but also training them in the ways that we need to be thinking about problems now and in the future.

Q: You’ve attended multiple annual meetings and presented posters. What value have you taken out of them, and would you recommend the experience to others?

A: Absolutely. I think as people develop, it’s good to always learn new skills, and my clinical research is an area that I would actually like to build up. So I’ve had a little bit of exposure, and it’s been nice to be able to draw from the resources of SHM and be able to partake. We presented something last year, which was a really neat experience, and we’re looking to bring some new faculty this year and encourage them to get involved in the scholarship process. These are the kinds of things that can really help hone skills, and that’s a good thing.

Q: Once you’re inside the doors of a New York City hospital, is daily practice much different than anywhere else?

A: I would say yes and no. I would say no in that I think all hospitals are really neat places and really incredible places. I heard somebody say once at a talk that hospitals were places of refuge, and I really do believe that. That being said, I think there is something slightly unique about New York City in a lot of ways. Certainly the challenges that New York City hospitals face are somewhat unique in terms of patient population, difficulty in socioeconomic factors, insurance issues. I think they are really fun places to work, but they’re not for the faint of heart.

Richard Quinn is a freelance writer in New Jersey.

Rajan Gurunathan, MD, was an undergraduate student at Johns Hopkins University in Baltimore in the early 1990s weighing his career options.

“I went through a lot of permutations, actually,” he says. “Scientist, clinical researcher, doctor, physician/scientist—all of those things entered my mind at some point.”

He applied to dual-track MD and PhD programs, but ultimately decided that interacting with people—patients in particular—was the goal for him. He earned his medical degree from UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., and completed his internship in the department of medicine at St. Luke’s-Roosevelt Hospital Center in New York City, not far from where he grew up as a child in northern New Jersey.

And he never left.

I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

Dr. Gurunathan has risen through the ranks at St. Luke’s-Roosevelt, from resident to chief resident to chief of the section of hospital medicine. He is a faculty member for the Clinical Quality Fellowship Program at the Great New York Hospital Association and an assistant clinical professor of medicine at Columbia University College of Physicians and Surgeons in New York.

His long tenure at St. Luke’s-Roosevelt has been “an incredible experience because I really get a sense and feeling of commitment from the community,” he adds. “I’ve seen it grow over time and see how the needs have changed and how the service the hospital has been able to provide has only grown over time.”

After several years of presenting posters at SHM’s annual meetings, Dr. Gurunathan joined Team Hospitalist in April 2012 to become an even more active member of his specialty.

QUESTION: When you started as an intern 15 years ago, did you expect that you’d still be at the same institution?

Answer: No, I wouldn’t have expected that at all. In fact, there was a time where I was briefly considering a general medicine fellowship at Johns Hopkins, and I was prepared to go there. And family circumstances, etc., made me decide not to move on and to make a commitment and join the department as faculty, first as a chief and then as faculty. And I was really lucky to have those opportunities, because while my course didn’t go exactly the way that I’d planned, I wouldn’t have changed a thing.

Q: When you now deal with the residents and younger staff members, what’s that experience like for you?

A: It’s a really neat experience, and often brings a chuckle to my face when I see that they’re frustrated about the same things, because I can certainly commiserate. But I can really also see the value of what they provide every day, and having been in their shoes, I know a little bit about what they’ve been through and the work that they do. So I have a real appreciation for that.

Q: What brought you to hospital medicine?

A: I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

Q: Is there something specific about the setting that’s kept you in the academic world?

A: A lot of things, actually. As I mentioned, hospitals in general should have a collegial nature. Again, it’s a really nice place where people share a unique common goal of banding together and fighting a goal, and academic departments are the same. So it’s being with people with like-minded intellectual interests. And we’re fortunate enough to have a number of strong mentors within the department who have had a lot of clinical training and bring a lot of experience and a wealth of knowledge, and being able to utilize their experience and draw from their experiences only makes people better clinicians. And we’re fortunate enough to have a pretty supportive department in general where there is a lot of collegiality and camaraderie.

Q: As an administrator, what is the value of being an SHM member, to you?

A: I think what I’ve seen administratively is the changing face of healthcare and how hospitals are going to need to continue to transform with time due to things that are both regulatory- and quality-of-care-based, in terms of improving outcomes and keeping people healthy. SHM has really embraced [those changes] and taken them head-on for really important reasons, not only in terms of helping people adapt to the changing landscape, but also training them in the ways that we need to be thinking about problems now and in the future.

Q: You’ve attended multiple annual meetings and presented posters. What value have you taken out of them, and would you recommend the experience to others?

A: Absolutely. I think as people develop, it’s good to always learn new skills, and my clinical research is an area that I would actually like to build up. So I’ve had a little bit of exposure, and it’s been nice to be able to draw from the resources of SHM and be able to partake. We presented something last year, which was a really neat experience, and we’re looking to bring some new faculty this year and encourage them to get involved in the scholarship process. These are the kinds of things that can really help hone skills, and that’s a good thing.

Q: Once you’re inside the doors of a New York City hospital, is daily practice much different than anywhere else?

A: I would say yes and no. I would say no in that I think all hospitals are really neat places and really incredible places. I heard somebody say once at a talk that hospitals were places of refuge, and I really do believe that. That being said, I think there is something slightly unique about New York City in a lot of ways. Certainly the challenges that New York City hospitals face are somewhat unique in terms of patient population, difficulty in socioeconomic factors, insurance issues. I think they are really fun places to work, but they’re not for the faint of heart.

Richard Quinn is a freelance writer in New Jersey.