Do you view your medical school and residency training the same way I see mine? I think I received really good training and education in the clinical knowledge base (e.g. which tests and drugs are useful in pneumonia) but really poor training and guidance into how to get the job done efficiently and organize my career. My problem was an inability to separate the good and bad advice about organizing my work; I essentially tried to follow all advice.

An energetic ENT attending who really seemed to care about students and trainees told me during my third year of medical school that failure to palpate the floor of the mouth on every new patient was a failure to do an adequate exam, not just on the ENT service but also on every patient in the hospital. While less dogmatic about it, he also encouraged documenting the presence or absence of a Darwinian tubercle. So I was determined to do these things—on all patients. No shortcuts for me!

But on my next rotation a few weeks later, I noticed that none of the neurosurgery attendings palpated the floor of the mouth on their patients. I stopped doing it routinely not long after.

By the time I was a resident, I was catching on to the fact that, like the ENT attending, my superiors were sometimes providing misguided, or even bad, advice. Meanwhile, I got a little better at knowing the difference. If I didn’t hear the same advice from multiple people, I gave it much less credibility. But if enough different people gave me advice, I typically accepted it as well-founded and tried to follow it.

Bad Advice: Keeping Up with the Literature

There must have been dozens of people who told me that the best strategy to keep up with the medical literature was to pick one, maybe two, medical journals with original scientific research and read all the articles in every issue. So that is exactly what I tried to do.

But after a few years, I decided that “pick one journal and read every issue” was bad advice. I think it is a poor way for most doctors in community practice to keep up with the latest and most important information. How many of us can really understand the strengths and weaknesses of study design and statistics? For example, outside of those who spend their career writing and analyzing original research (and are proficient in the complex and counterintuitive statistics they contain), how many of us have been able to make sense of all the conflicting studies of perioperative beta-blocker use? Outcomes of these studies vary a lot. So what should we do in clinical practice?

Better Advice: Keep Up with Literature

I finally concluded that in the pre-Internet era, the best way to keep up was to let academicians and researchers study the original research articles and write review articles, editorials, and letters to the editor. These seemed to pay much greater dividends in improving my clinical practice.

The traditional literature sources I’ve relied on for these kinds of articles are the New England Journal of Medicine, Annals of Internal Medicine, and the Cleveland Clinic Journal of Medicine. The latter is my favorite; it provides concise articles written to address very focused questions that come up all the time in my practice.

Since the arrival of the Internet, there are so many more ways to keep up with literature other than just deciding which journals and articles you’ll read. I’ll leave it to others to provide thoughts about that.

Get a Gimmick: Good Advice?

It was a tradition in my residency that at the end of a month “on the wards,” the attending (who rounded with us seven days a week for the whole month) took the whole team out to lunch or dinner. I think this once-common tradition has largely disappeared as a result of both the residency work-hour restrictions and attendings usually staying “on service” for only a couple of weeks, rather than the whole month. Right? (I’d love to hear from someone at a place where the attending-led, end-of-the-month team social event is still a common practice.)

On every such occasion, I would ask the attending, “What do you know now about ensuring a good career as a doctor that you wish you knew when you were a resident?” A number of the attendings didn’t seem willing to give it much thought: “I dunno,” most would say. “Maybe just make sure to leave time for nonprofessional activities like regular exercise.” Others gave generic advice: “Be sure to keep up with the literature.”

But one successful GI attending surprised me. When asked to provide career advice, he said, “Get a gimmick.” This is not what a young and idealistic trainee wanted to hear. A gimmick sounds like cheating or taking a shortcut.

He went on to explain that he meant that focusing only on being a good doctor for the next patient on your list, although it might be the most important thing you can do, might not be enough to keep your career interesting and energizing. So he advocated for finding an additional special interest, such as becoming a super-expert in a particular disease (e.g. you’re the snakebite expert at your hospital) or becoming a quality-improvement (QI) expert for your institution.

I’ve since fully embraced this idea and consider it among the best pearls of wisdom I’ve collected in my career. But “gimmick” is probably the wrong word choice; maybe it’s better to just say that you should get a special interest.

It would be best if you are the only one, or one of only a few, who pursues an area of interest at your institution. It can be rewarding to be the “go-to guy” for certain issues. And it might even lead to invitations to speak on the topic elsewhere, additional compensation, etc.

For nonacademic hospitalists, most of us will see our direct-patient-care activities as the core of what defines our career. I do many things other than patient care, but when I’m asked by a stranger about my occupation, I almost always end up talking about being a doctor who takes care of hospitalized patients. But my non-patient-care activities, my “gimmicks,” have been vitally important and satisfying components of my career.

If I were an attending at an end-of-the-month dinner with my team, I would talk with them about the value of developing these additional interests as part of a healthy and balanced career. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

Do you view your medical school and residency training the same way I see mine? I think I received really good training and education in the clinical knowledge base (e.g. which tests and drugs are useful in pneumonia) but really poor training and guidance into how to get the job done efficiently and organize my career. My problem was an inability to separate the good and bad advice about organizing my work; I essentially tried to follow all advice.

An energetic ENT attending who really seemed to care about students and trainees told me during my third year of medical school that failure to palpate the floor of the mouth on every new patient was a failure to do an adequate exam, not just on the ENT service but also on every patient in the hospital. While less dogmatic about it, he also encouraged documenting the presence or absence of a Darwinian tubercle. So I was determined to do these things—on all patients. No shortcuts for me!

But on my next rotation a few weeks later, I noticed that none of the neurosurgery attendings palpated the floor of the mouth on their patients. I stopped doing it routinely not long after.

By the time I was a resident, I was catching on to the fact that, like the ENT attending, my superiors were sometimes providing misguided, or even bad, advice. Meanwhile, I got a little better at knowing the difference. If I didn’t hear the same advice from multiple people, I gave it much less credibility. But if enough different people gave me advice, I typically accepted it as well-founded and tried to follow it.

Bad Advice: Keeping Up with the Literature

There must have been dozens of people who told me that the best strategy to keep up with the medical literature was to pick one, maybe two, medical journals with original scientific research and read all the articles in every issue. So that is exactly what I tried to do.

But after a few years, I decided that “pick one journal and read every issue” was bad advice. I think it is a poor way for most doctors in community practice to keep up with the latest and most important information. How many of us can really understand the strengths and weaknesses of study design and statistics? For example, outside of those who spend their career writing and analyzing original research (and are proficient in the complex and counterintuitive statistics they contain), how many of us have been able to make sense of all the conflicting studies of perioperative beta-blocker use? Outcomes of these studies vary a lot. So what should we do in clinical practice?

Better Advice: Keep Up with Literature

I finally concluded that in the pre-Internet era, the best way to keep up was to let academicians and researchers study the original research articles and write review articles, editorials, and letters to the editor. These seemed to pay much greater dividends in improving my clinical practice.

The traditional literature sources I’ve relied on for these kinds of articles are the New England Journal of Medicine, Annals of Internal Medicine, and the Cleveland Clinic Journal of Medicine. The latter is my favorite; it provides concise articles written to address very focused questions that come up all the time in my practice.

Since the arrival of the Internet, there are so many more ways to keep up with literature other than just deciding which journals and articles you’ll read. I’ll leave it to others to provide thoughts about that.

Get a Gimmick: Good Advice?

It was a tradition in my residency that at the end of a month “on the wards,” the attending (who rounded with us seven days a week for the whole month) took the whole team out to lunch or dinner. I think this once-common tradition has largely disappeared as a result of both the residency work-hour restrictions and attendings usually staying “on service” for only a couple of weeks, rather than the whole month. Right? (I’d love to hear from someone at a place where the attending-led, end-of-the-month team social event is still a common practice.)

On every such occasion, I would ask the attending, “What do you know now about ensuring a good career as a doctor that you wish you knew when you were a resident?” A number of the attendings didn’t seem willing to give it much thought: “I dunno,” most would say. “Maybe just make sure to leave time for nonprofessional activities like regular exercise.” Others gave generic advice: “Be sure to keep up with the literature.”

But one successful GI attending surprised me. When asked to provide career advice, he said, “Get a gimmick.” This is not what a young and idealistic trainee wanted to hear. A gimmick sounds like cheating or taking a shortcut.

He went on to explain that he meant that focusing only on being a good doctor for the next patient on your list, although it might be the most important thing you can do, might not be enough to keep your career interesting and energizing. So he advocated for finding an additional special interest, such as becoming a super-expert in a particular disease (e.g. you’re the snakebite expert at your hospital) or becoming a quality-improvement (QI) expert for your institution.

I’ve since fully embraced this idea and consider it among the best pearls of wisdom I’ve collected in my career. But “gimmick” is probably the wrong word choice; maybe it’s better to just say that you should get a special interest.

It would be best if you are the only one, or one of only a few, who pursues an area of interest at your institution. It can be rewarding to be the “go-to guy” for certain issues. And it might even lead to invitations to speak on the topic elsewhere, additional compensation, etc.

For nonacademic hospitalists, most of us will see our direct-patient-care activities as the core of what defines our career. I do many things other than patient care, but when I’m asked by a stranger about my occupation, I almost always end up talking about being a doctor who takes care of hospitalized patients. But my non-patient-care activities, my “gimmicks,” have been vitally important and satisfying components of my career.

If I were an attending at an end-of-the-month dinner with my team, I would talk with them about the value of developing these additional interests as part of a healthy and balanced career. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

Do you view your medical school and residency training the same way I see mine? I think I received really good training and education in the clinical knowledge base (e.g. which tests and drugs are useful in pneumonia) but really poor training and guidance into how to get the job done efficiently and organize my career. My problem was an inability to separate the good and bad advice about organizing my work; I essentially tried to follow all advice.

An energetic ENT attending who really seemed to care about students and trainees told me during my third year of medical school that failure to palpate the floor of the mouth on every new patient was a failure to do an adequate exam, not just on the ENT service but also on every patient in the hospital. While less dogmatic about it, he also encouraged documenting the presence or absence of a Darwinian tubercle. So I was determined to do these things—on all patients. No shortcuts for me!

But on my next rotation a few weeks later, I noticed that none of the neurosurgery attendings palpated the floor of the mouth on their patients. I stopped doing it routinely not long after.

By the time I was a resident, I was catching on to the fact that, like the ENT attending, my superiors were sometimes providing misguided, or even bad, advice. Meanwhile, I got a little better at knowing the difference. If I didn’t hear the same advice from multiple people, I gave it much less credibility. But if enough different people gave me advice, I typically accepted it as well-founded and tried to follow it.

Bad Advice: Keeping Up with the Literature

There must have been dozens of people who told me that the best strategy to keep up with the medical literature was to pick one, maybe two, medical journals with original scientific research and read all the articles in every issue. So that is exactly what I tried to do.

But after a few years, I decided that “pick one journal and read every issue” was bad advice. I think it is a poor way for most doctors in community practice to keep up with the latest and most important information. How many of us can really understand the strengths and weaknesses of study design and statistics? For example, outside of those who spend their career writing and analyzing original research (and are proficient in the complex and counterintuitive statistics they contain), how many of us have been able to make sense of all the conflicting studies of perioperative beta-blocker use? Outcomes of these studies vary a lot. So what should we do in clinical practice?

Better Advice: Keep Up with Literature

I finally concluded that in the pre-Internet era, the best way to keep up was to let academicians and researchers study the original research articles and write review articles, editorials, and letters to the editor. These seemed to pay much greater dividends in improving my clinical practice.

The traditional literature sources I’ve relied on for these kinds of articles are the New England Journal of Medicine, Annals of Internal Medicine, and the Cleveland Clinic Journal of Medicine. The latter is my favorite; it provides concise articles written to address very focused questions that come up all the time in my practice.

Since the arrival of the Internet, there are so many more ways to keep up with literature other than just deciding which journals and articles you’ll read. I’ll leave it to others to provide thoughts about that.

Get a Gimmick: Good Advice?

It was a tradition in my residency that at the end of a month “on the wards,” the attending (who rounded with us seven days a week for the whole month) took the whole team out to lunch or dinner. I think this once-common tradition has largely disappeared as a result of both the residency work-hour restrictions and attendings usually staying “on service” for only a couple of weeks, rather than the whole month. Right? (I’d love to hear from someone at a place where the attending-led, end-of-the-month team social event is still a common practice.)

On every such occasion, I would ask the attending, “What do you know now about ensuring a good career as a doctor that you wish you knew when you were a resident?” A number of the attendings didn’t seem willing to give it much thought: “I dunno,” most would say. “Maybe just make sure to leave time for nonprofessional activities like regular exercise.” Others gave generic advice: “Be sure to keep up with the literature.”

But one successful GI attending surprised me. When asked to provide career advice, he said, “Get a gimmick.” This is not what a young and idealistic trainee wanted to hear. A gimmick sounds like cheating or taking a shortcut.

He went on to explain that he meant that focusing only on being a good doctor for the next patient on your list, although it might be the most important thing you can do, might not be enough to keep your career interesting and energizing. So he advocated for finding an additional special interest, such as becoming a super-expert in a particular disease (e.g. you’re the snakebite expert at your hospital) or becoming a quality-improvement (QI) expert for your institution.

I’ve since fully embraced this idea and consider it among the best pearls of wisdom I’ve collected in my career. But “gimmick” is probably the wrong word choice; maybe it’s better to just say that you should get a special interest.

It would be best if you are the only one, or one of only a few, who pursues an area of interest at your institution. It can be rewarding to be the “go-to guy” for certain issues. And it might even lead to invitations to speak on the topic elsewhere, additional compensation, etc.

For nonacademic hospitalists, most of us will see our direct-patient-care activities as the core of what defines our career. I do many things other than patient care, but when I’m asked by a stranger about my occupation, I almost always end up talking about being a doctor who takes care of hospitalized patients. But my non-patient-care activities, my “gimmicks,” have been vitally important and satisfying components of my career.

If I were an attending at an end-of-the-month dinner with my team, I would talk with them about the value of developing these additional interests as part of a healthy and balanced career. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

I recently was appointed the director of my hospitalist group at a 53-bed hospital in rural Wisconsin. Including myself, we have three hospitalist FTEs, one part-time hospitalist, and one nurse practitioner; we are all seasoned internists, but we are relatively new to HM and the 24/7 nature of the business. The hospital administration has charged me with making the program more efficient. What do you suggest I do to improve our efficiency and standard of patient care?

Andrew Neubauer, DO, MPH

Dr. Hospitalist responds: Congratulations aside, one of the first items at hand is to understand the question being asked. Your hospital administration potentially has many moving parts: a CEO for vision, a chief operating officer (COO) for execution, a chief medical officer (CMO) for medical staff initiatives, and a chief financial officer (CFO) for the hard truth of hospital finances.

Before you take any steps to improve efficiency, you need to ask what “efficiency” means.

• Is it the CFO asking for better financial returns?
• Is the CEO trying to woo a large surgical group and needs to tout his high-functioning hospitalist group to make it more attractive?
• Does the CMO want to improve staff relations and primary-care referrals?
• Does the COO want higher patient satisfaction?

Whatever the answer is, the first thing to do is define the question. So, in a non-confrontational, inquisitive way, ask your administrators what they mean by “efficiency.”

The immediate corollary to this is that you must then get baseline data. You have to know where you are starting from in order to show demonstrable progress toward a goal. Whether it’s the case-mix index, the readmission rate, or adherence to protocols, defining the baseline and the goal is paramount.

Why is this so important? You need to be able to prove you met the goals, because as soon as you meet this one, a new one will be placed in front of you.

Let’s assume, by way of example, that “efficiency” in this case means an earlier time of discharge. For starters, ask what the average time of discharge is now, how it is measured, what the desired result is, and why. Once you have that information, look for ways that your group can improve, and make sure that the hospital is measuring you only on things you can control. Your physicians can determine the time the discharge order is written, but they have no say in when the patient physically leaves the building. It might seem like a subtle distinction, but it can make all the difference depending on how “time of discharge” is defined. Don’t promise what you can’t deliver—you’ll disappoint both the hospital and your practice partners.

Going forward, you should keep a playbook of past goals asked of you, and your group’s actions. This is incredibly important if (when) your contract comes up for renewal, since you will need to gently (and sometimes forcefully) remind the hospital of your group’s value. In addition, the other main constant in any hospital administration is change; last I checked, the average tenure for a hospital CEO is four years. You want to always be able to communicate your group’s achievements to serve as a visible reminder of your central role in the hospital.

As the newly appointed medical director, everyone is looking to you for answers. Just make sure to focus on the question first. TH

I recently was appointed the director of my hospitalist group at a 53-bed hospital in rural Wisconsin. Including myself, we have three hospitalist FTEs, one part-time hospitalist, and one nurse practitioner; we are all seasoned internists, but we are relatively new to HM and the 24/7 nature of the business. The hospital administration has charged me with making the program more efficient. What do you suggest I do to improve our efficiency and standard of patient care?

Andrew Neubauer, DO, MPH

Dr. Hospitalist responds: Congratulations aside, one of the first items at hand is to understand the question being asked. Your hospital administration potentially has many moving parts: a CEO for vision, a chief operating officer (COO) for execution, a chief medical officer (CMO) for medical staff initiatives, and a chief financial officer (CFO) for the hard truth of hospital finances.

Before you take any steps to improve efficiency, you need to ask what “efficiency” means.

• Is it the CFO asking for better financial returns?
• Is the CEO trying to woo a large surgical group and needs to tout his high-functioning hospitalist group to make it more attractive?
• Does the CMO want to improve staff relations and primary-care referrals?
• Does the COO want higher patient satisfaction?

Whatever the answer is, the first thing to do is define the question. So, in a non-confrontational, inquisitive way, ask your administrators what they mean by “efficiency.”

The immediate corollary to this is that you must then get baseline data. You have to know where you are starting from in order to show demonstrable progress toward a goal. Whether it’s the case-mix index, the readmission rate, or adherence to protocols, defining the baseline and the goal is paramount.

Why is this so important? You need to be able to prove you met the goals, because as soon as you meet this one, a new one will be placed in front of you.

Let’s assume, by way of example, that “efficiency” in this case means an earlier time of discharge. For starters, ask what the average time of discharge is now, how it is measured, what the desired result is, and why. Once you have that information, look for ways that your group can improve, and make sure that the hospital is measuring you only on things you can control. Your physicians can determine the time the discharge order is written, but they have no say in when the patient physically leaves the building. It might seem like a subtle distinction, but it can make all the difference depending on how “time of discharge” is defined. Don’t promise what you can’t deliver—you’ll disappoint both the hospital and your practice partners.

Going forward, you should keep a playbook of past goals asked of you, and your group’s actions. This is incredibly important if (when) your contract comes up for renewal, since you will need to gently (and sometimes forcefully) remind the hospital of your group’s value. In addition, the other main constant in any hospital administration is change; last I checked, the average tenure for a hospital CEO is four years. You want to always be able to communicate your group’s achievements to serve as a visible reminder of your central role in the hospital.

As the newly appointed medical director, everyone is looking to you for answers. Just make sure to focus on the question first. TH

I recently was appointed the director of my hospitalist group at a 53-bed hospital in rural Wisconsin. Including myself, we have three hospitalist FTEs, one part-time hospitalist, and one nurse practitioner; we are all seasoned internists, but we are relatively new to HM and the 24/7 nature of the business. The hospital administration has charged me with making the program more efficient. What do you suggest I do to improve our efficiency and standard of patient care?

Andrew Neubauer, DO, MPH

Dr. Hospitalist responds: Congratulations aside, one of the first items at hand is to understand the question being asked. Your hospital administration potentially has many moving parts: a CEO for vision, a chief operating officer (COO) for execution, a chief medical officer (CMO) for medical staff initiatives, and a chief financial officer (CFO) for the hard truth of hospital finances.

Before you take any steps to improve efficiency, you need to ask what “efficiency” means.

• Is it the CFO asking for better financial returns?
• Is the CEO trying to woo a large surgical group and needs to tout his high-functioning hospitalist group to make it more attractive?
• Does the CMO want to improve staff relations and primary-care referrals?
• Does the COO want higher patient satisfaction?

Whatever the answer is, the first thing to do is define the question. So, in a non-confrontational, inquisitive way, ask your administrators what they mean by “efficiency.”

The immediate corollary to this is that you must then get baseline data. You have to know where you are starting from in order to show demonstrable progress toward a goal. Whether it’s the case-mix index, the readmission rate, or adherence to protocols, defining the baseline and the goal is paramount.

Why is this so important? You need to be able to prove you met the goals, because as soon as you meet this one, a new one will be placed in front of you.

Let’s assume, by way of example, that “efficiency” in this case means an earlier time of discharge. For starters, ask what the average time of discharge is now, how it is measured, what the desired result is, and why. Once you have that information, look for ways that your group can improve, and make sure that the hospital is measuring you only on things you can control. Your physicians can determine the time the discharge order is written, but they have no say in when the patient physically leaves the building. It might seem like a subtle distinction, but it can make all the difference depending on how “time of discharge” is defined. Don’t promise what you can’t deliver—you’ll disappoint both the hospital and your practice partners.

Going forward, you should keep a playbook of past goals asked of you, and your group’s actions. This is incredibly important if (when) your contract comes up for renewal, since you will need to gently (and sometimes forcefully) remind the hospital of your group’s value. In addition, the other main constant in any hospital administration is change; last I checked, the average tenure for a hospital CEO is four years. You want to always be able to communicate your group’s achievements to serve as a visible reminder of your central role in the hospital.

As the newly appointed medical director, everyone is looking to you for answers. Just make sure to focus on the question first. TH

Click here to listen to Dr. Rosen

Click here to listen to Dr. Schnipper

Click here to listen to Dr. Rosen

Click here to listen to Dr. Schnipper

Click here to listen to Dr. Rosen

Click here to listen to Dr. Schnipper

Click here to listen to Dr. Kocher

Click here to listen to Dr. Kocher

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Click here to listen to Dr. Li

Click here to listen to Dr. Li

Click here to listen to Dr. Li

GRAPEVINE, Texas—Community hospitalist compensation rose slightly last year to its highest level, according to preliminary SHM/MGMA survey data revealed at HM11. A national median wasn’t available, but SHM cofounder John Nelson, MD, MHM, says survey figures for compensation, including bonuses, rose roughly 3% over the prior year. Formal survey results are to be released in June.

According to Dr. Nelson, a nonacademic hospitalist in the Northeast seeing only adult patients earns roughly $212,000 per year. In the West, the number ticks up slightly to $213,000. Salaries rose at a higher rate in the Midwest (to $224,000) and the Southeast (to $246,000).

Sound Inpatient Physicians president and CEO Robert Bessler, MD, says survey data for compensation can be helpful but that individual HM groups need to be acutely aware of what hospitalists earn in their “micro-market” more than in their corner of the country. “The macro numbers are what they are,” he adds. “It’s not going to get less any time soon.”

Dr. Nelson also says that the average financial subsidy for HM groups has risen to $132,000 per FTE hospitalist, a marked jump from the roughly $100,000 level SHM reported in its past two surveys. Some 19% of hospitalist practices reported no support from their hospitals, a point that intrigues new SHM President Joseph Li, MD, SFHM, assistant professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston.

Dr. Li wonders how such a large percentage of practices operate independent of financial support, given that the vast majority of programs that do rely on that funding seem to be needing more of it. In short, he says: “Are we looking at two business models or two care models?”

Richard Quinn is a freelance writer based in New Jersey.

GRAPEVINE, Texas—Community hospitalist compensation rose slightly last year to its highest level, according to preliminary SHM/MGMA survey data revealed at HM11. A national median wasn’t available, but SHM cofounder John Nelson, MD, MHM, says survey figures for compensation, including bonuses, rose roughly 3% over the prior year. Formal survey results are to be released in June.

According to Dr. Nelson, a nonacademic hospitalist in the Northeast seeing only adult patients earns roughly $212,000 per year. In the West, the number ticks up slightly to $213,000. Salaries rose at a higher rate in the Midwest (to $224,000) and the Southeast (to $246,000).

Sound Inpatient Physicians president and CEO Robert Bessler, MD, says survey data for compensation can be helpful but that individual HM groups need to be acutely aware of what hospitalists earn in their “micro-market” more than in their corner of the country. “The macro numbers are what they are,” he adds. “It’s not going to get less any time soon.”

Dr. Nelson also says that the average financial subsidy for HM groups has risen to $132,000 per FTE hospitalist, a marked jump from the roughly $100,000 level SHM reported in its past two surveys. Some 19% of hospitalist practices reported no support from their hospitals, a point that intrigues new SHM President Joseph Li, MD, SFHM, assistant professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston.

Dr. Li wonders how such a large percentage of practices operate independent of financial support, given that the vast majority of programs that do rely on that funding seem to be needing more of it. In short, he says: “Are we looking at two business models or two care models?”

Richard Quinn is a freelance writer based in New Jersey.

GRAPEVINE, Texas—Community hospitalist compensation rose slightly last year to its highest level, according to preliminary SHM/MGMA survey data revealed at HM11. A national median wasn’t available, but SHM cofounder John Nelson, MD, MHM, says survey figures for compensation, including bonuses, rose roughly 3% over the prior year. Formal survey results are to be released in June.

According to Dr. Nelson, a nonacademic hospitalist in the Northeast seeing only adult patients earns roughly $212,000 per year. In the West, the number ticks up slightly to $213,000. Salaries rose at a higher rate in the Midwest (to $224,000) and the Southeast (to $246,000).

Sound Inpatient Physicians president and CEO Robert Bessler, MD, says survey data for compensation can be helpful but that individual HM groups need to be acutely aware of what hospitalists earn in their “micro-market” more than in their corner of the country. “The macro numbers are what they are,” he adds. “It’s not going to get less any time soon.”

Dr. Nelson also says that the average financial subsidy for HM groups has risen to $132,000 per FTE hospitalist, a marked jump from the roughly $100,000 level SHM reported in its past two surveys. Some 19% of hospitalist practices reported no support from their hospitals, a point that intrigues new SHM President Joseph Li, MD, SFHM, assistant professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston.

Dr. Li wonders how such a large percentage of practices operate independent of financial support, given that the vast majority of programs that do rely on that funding seem to be needing more of it. In short, he says: “Are we looking at two business models or two care models?”

Richard Quinn is a freelance writer based in New Jersey.

Click here to listen to Dr. Merli discuss the new anticoagulants

Click here to listen to Howard Bremer discuss the long history of warfarin

Click here to listen to Dr. Merli discuss the new anticoagulants

Click here to listen to Howard Bremer discuss the long history of warfarin

Click here to listen to Dr. Merli discuss the new anticoagulants

Click here to listen to Howard Bremer discuss the long history of warfarin

My name is Joe Li, MD, SFHM. I am a hospitalist who works at Beth Israel Deaconess Medical Center in Boston. I have the privilege of serving as the SHM president for the upcoming year. I thank each of you for entrusting me with this important role.

Given the trust you have shared with me, I think it is only fair that I tell you a little bit about myself. For the “birthers” in the crowd, your fears have been realized. I was not born in this country; I was not even born in Panama. Not only were my parents immigrants—like many of you or your ancestors—I am also an immigrant to this country.

While I live now in Boston, I did not grow up there. Like many of you, I grew up in the middle part of the country. Like our immediate past president, Jeff Wiese, MD, SFHM, I spent my formative years in Oklahoma. My parents were not poor, but they were far from wealthy. Like most of you, I grew up in middle-class America.

Although I now have a teaching appointment at Harvard Medical School, neither my parents nor I ever paid tuition at a private school. Like many of you, I received my schooling at a public university.

I completed my undergraduate and medical school studies at the University of Oklahoma, and I moved to Boston for my post-graduate training. In fact, I was the first hospitalist at Beth Israel Deaconess Medical Center in 1998.

I joined the National Association of Inpatient Physicians (now SHM) as a charter member, and what I have learned from spending time with many of you over the years is that my story is not unique—there is tremendous diversity throughout SHM, but we are held together by the shared vision of improving care for our hospitalized patients.

For those of you new to SHM, I want to make it clear that SHM is not run by the president but by its collective members. Yes, we do have an organizational structure, with an elected board of directors and an elected executive committee made up of the president-elect, the president, the immediate past president, and the CEO. This past year, I served as the president-elect and had the wonderful opportunity of working with Dr. Wiese, our immediate past president, Scott Flanders, MD, SFHM, and our CEO, Larry Wellikson, MD, SFHM.

I can tell you firsthand about the tireless work that each of these physicians puts in to serve our patients and our profession. Each is an incredible leader, and I thank them, as well as our board of directors and SHM staff members, for all the work they put in to keep our organization running smoothly. While their work is not obvious day to day, there are many others who serve our organization in an invisible role. These include our committee leaders and committee members. I also thank you for all of your hard work for SHM and for our profession.

Despite all the hard work that has been done, there is still so much to do. I am personally asking each one of you to serve HM in your own way. Being an SHM member and attending SHM meetings are ways of serving, but I challenge each of you to do more. For some of you, it could be setting an expectation that all of your hospitalists join SHM and attend SHM meetings. For others, it could be helping to organize and lead your local chapters.

There is a role for each of us in HM, and I believe strongly that if we are to improve the care of our patients, each of us must take responsibility by serving our profession. There is no role too small. Each one of us must lead in our own way.

I look forward to the opportunity this year of speaking with each of you, not only as I travel the country to the various SHM meetings and chapter events, but also through this monthly column. I hope to share with you my observations of the happenings throughout hospital medicine. I expect to see and hear remarkable work being done by hospitalists across the country in our continued effort to bring increasing healthcare value to our patients. TH

Dr. Li is president of SHM, associate professor of medicine at Harvard Medical School in Boston, and director of the hospital medicine program and associate chief of the division of general medicine and primary care at Beth Israel Deaconess Medical Center.

My name is Joe Li, MD, SFHM. I am a hospitalist who works at Beth Israel Deaconess Medical Center in Boston. I have the privilege of serving as the SHM president for the upcoming year. I thank each of you for entrusting me with this important role.

Given the trust you have shared with me, I think it is only fair that I tell you a little bit about myself. For the “birthers” in the crowd, your fears have been realized. I was not born in this country; I was not even born in Panama. Not only were my parents immigrants—like many of you or your ancestors—I am also an immigrant to this country.

While I live now in Boston, I did not grow up there. Like many of you, I grew up in the middle part of the country. Like our immediate past president, Jeff Wiese, MD, SFHM, I spent my formative years in Oklahoma. My parents were not poor, but they were far from wealthy. Like most of you, I grew up in middle-class America.

Although I now have a teaching appointment at Harvard Medical School, neither my parents nor I ever paid tuition at a private school. Like many of you, I received my schooling at a public university.

I completed my undergraduate and medical school studies at the University of Oklahoma, and I moved to Boston for my post-graduate training. In fact, I was the first hospitalist at Beth Israel Deaconess Medical Center in 1998.

I joined the National Association of Inpatient Physicians (now SHM) as a charter member, and what I have learned from spending time with many of you over the years is that my story is not unique—there is tremendous diversity throughout SHM, but we are held together by the shared vision of improving care for our hospitalized patients.

For those of you new to SHM, I want to make it clear that SHM is not run by the president but by its collective members. Yes, we do have an organizational structure, with an elected board of directors and an elected executive committee made up of the president-elect, the president, the immediate past president, and the CEO. This past year, I served as the president-elect and had the wonderful opportunity of working with Dr. Wiese, our immediate past president, Scott Flanders, MD, SFHM, and our CEO, Larry Wellikson, MD, SFHM.

I can tell you firsthand about the tireless work that each of these physicians puts in to serve our patients and our profession. Each is an incredible leader, and I thank them, as well as our board of directors and SHM staff members, for all the work they put in to keep our organization running smoothly. While their work is not obvious day to day, there are many others who serve our organization in an invisible role. These include our committee leaders and committee members. I also thank you for all of your hard work for SHM and for our profession.

Despite all the hard work that has been done, there is still so much to do. I am personally asking each one of you to serve HM in your own way. Being an SHM member and attending SHM meetings are ways of serving, but I challenge each of you to do more. For some of you, it could be setting an expectation that all of your hospitalists join SHM and attend SHM meetings. For others, it could be helping to organize and lead your local chapters.

There is a role for each of us in HM, and I believe strongly that if we are to improve the care of our patients, each of us must take responsibility by serving our profession. There is no role too small. Each one of us must lead in our own way.

I look forward to the opportunity this year of speaking with each of you, not only as I travel the country to the various SHM meetings and chapter events, but also through this monthly column. I hope to share with you my observations of the happenings throughout hospital medicine. I expect to see and hear remarkable work being done by hospitalists across the country in our continued effort to bring increasing healthcare value to our patients. TH

Dr. Li is president of SHM, associate professor of medicine at Harvard Medical School in Boston, and director of the hospital medicine program and associate chief of the division of general medicine and primary care at Beth Israel Deaconess Medical Center.

My name is Joe Li, MD, SFHM. I am a hospitalist who works at Beth Israel Deaconess Medical Center in Boston. I have the privilege of serving as the SHM president for the upcoming year. I thank each of you for entrusting me with this important role.

Given the trust you have shared with me, I think it is only fair that I tell you a little bit about myself. For the “birthers” in the crowd, your fears have been realized. I was not born in this country; I was not even born in Panama. Not only were my parents immigrants—like many of you or your ancestors—I am also an immigrant to this country.

While I live now in Boston, I did not grow up there. Like many of you, I grew up in the middle part of the country. Like our immediate past president, Jeff Wiese, MD, SFHM, I spent my formative years in Oklahoma. My parents were not poor, but they were far from wealthy. Like most of you, I grew up in middle-class America.

Although I now have a teaching appointment at Harvard Medical School, neither my parents nor I ever paid tuition at a private school. Like many of you, I received my schooling at a public university.

I completed my undergraduate and medical school studies at the University of Oklahoma, and I moved to Boston for my post-graduate training. In fact, I was the first hospitalist at Beth Israel Deaconess Medical Center in 1998.

I joined the National Association of Inpatient Physicians (now SHM) as a charter member, and what I have learned from spending time with many of you over the years is that my story is not unique—there is tremendous diversity throughout SHM, but we are held together by the shared vision of improving care for our hospitalized patients.

For those of you new to SHM, I want to make it clear that SHM is not run by the president but by its collective members. Yes, we do have an organizational structure, with an elected board of directors and an elected executive committee made up of the president-elect, the president, the immediate past president, and the CEO. This past year, I served as the president-elect and had the wonderful opportunity of working with Dr. Wiese, our immediate past president, Scott Flanders, MD, SFHM, and our CEO, Larry Wellikson, MD, SFHM.

I can tell you firsthand about the tireless work that each of these physicians puts in to serve our patients and our profession. Each is an incredible leader, and I thank them, as well as our board of directors and SHM staff members, for all the work they put in to keep our organization running smoothly. While their work is not obvious day to day, there are many others who serve our organization in an invisible role. These include our committee leaders and committee members. I also thank you for all of your hard work for SHM and for our profession.

Despite all the hard work that has been done, there is still so much to do. I am personally asking each one of you to serve HM in your own way. Being an SHM member and attending SHM meetings are ways of serving, but I challenge each of you to do more. For some of you, it could be setting an expectation that all of your hospitalists join SHM and attend SHM meetings. For others, it could be helping to organize and lead your local chapters.

There is a role for each of us in HM, and I believe strongly that if we are to improve the care of our patients, each of us must take responsibility by serving our profession. There is no role too small. Each one of us must lead in our own way.

I look forward to the opportunity this year of speaking with each of you, not only as I travel the country to the various SHM meetings and chapter events, but also through this monthly column. I hope to share with you my observations of the happenings throughout hospital medicine. I expect to see and hear remarkable work being done by hospitalists across the country in our continued effort to bring increasing healthcare value to our patients. TH

Dr. Li is president of SHM, associate professor of medicine at Harvard Medical School in Boston, and director of the hospital medicine program and associate chief of the division of general medicine and primary care at Beth Israel Deaconess Medical Center.

I stare; a brimming audience stares back. Two eyeballs battling thousands. Slightly uncomfortable, I shift my weight, trying to hide behind the glass podium. Two microphones snake out of the podium slithering together inches from my mouth. The attendees squirm, sidle to the edge of their seats, restless to depart. HM11 is trying to close; only I stand in its way.

A Herculean task lies before me—summarize the annual meeting in a 10-minute wrap-up session titled “What We’ve Learned.” How do you summarize four days, eight pre-courses, nine breakout tracks, and more than 100 presentations in a few minutes? A bead of forehead sweat forms; I clear my throat. Memories of the past few days slide-show across my mind. It occurs to me that the essence of the meeting is not contained in the data, the information, or the PowerPoint slides that were presented. Rather, the story of HM11 is best told through its quotes.

Patient Caps: Your Grandmother and Professionalism

“I worry about patient caps because the next patient could be your grandmother.”

—Joe Li, MD, SFHM, new president of SHM

“Patient caps are the greatest threat to the professionalism of the field.”

—Rob Bessler, MD, CEO, Sound Inpatient Physicians

These two quotes from the opening plenary focused on the 2011 HM compensation and productivity survey particularly stuck out. The most noteworthy exchange came when Drs. Li and Bressler commented on the appropriate number of daily encounters for a hospitalist. The quotes highlight two important points about patient volume, especially in the wake of the training regulations that limit the number of resident physician encounters, which can engender a “cap mentality.” One is that it matters; there is a safe amount of encounters that shouldn’t routinely be breached. Two is that in the heat of the moment, Patient 19 is as important as Patient 11 and should be treated as such. Contingency plans are essential, but our field is built on the moorings of professionalism—the focus needs to be on humans, not numbers.

Hospitalist Compensation: Increasing but Not as Juicy

“It’s not going to get less anytime soon.”

—Dr. Bressler

In commenting on the data showing that the average community hospitalist makes about $220,000 annually—a 3% increase over last year—while producing around 4,000 work RVUs—flat over last year—and that their academic counterparts made $173,000 on about 3,400 wRVUs, Dr. Bressler opined that the laws of supply and demand would dictate that salaries would continue to rise for the near term. Although I agree with Dr. Bressler, my guess is that future salary increases will be driven more by quality than quantity (more to follow below).

“Juice-to-squeeze ratio”

—John Nelson, MD, MHM, SHM cofounder

Dr. Nelson highlighted interesting data showing that the average pay per wRVU was approximately $54. However, he noted that the compensation per wRVU tends to peak at a certain level, after which compensation per wRVU falls. In other words, after, say, 4,000 wRVUs, the amount of compensation per wRVU diminishes such that seeing more patients benefits an individual hospitalist less. That is, lots of squeeze, little juice at the high end.

Reform: Variety, Change, and Waste

“Variety is about choice; change is not.”

—Cecil Wilson, MD, AMA president

“You won’t have many more conferences where you start by talking about work RVUs.”

—Bob Kocher, MD, former special assistant to President Obama

The highlight of the conference for me was Dr. Kocher’s behind-the-scenes look at what was a very publicly muddy event—the passage of ACA. Coming from a D.C. insider, this under-the-covers peek at the machinations that went into passing the healthcare reform bill was fascinating.

The key message, summarized in this comment referring to the opening plenary about hospitalist compensation and productivity, was that the future is quality and the future is now. In the very near future, we will be measured and paid based on our ability to effect quality outcomes, not patient encounters. The message was simple: It’s about quality, not quantity.

“It costs $7.50 for a healthcare transaction, versus 2 cents for a VISA transaction.”

—Dr. Kocher

A statistic I had not heard before, this quote sums up one of the major problems with American healthcare: waste. The $7.50 transaction he was referring to was the amount of money it takes to file a healthcare claim. We certainly feel it in the challenges of documentation, billing, and denials, but the system feels it in terms of high cost of capturing what in many ways should be as simple as swiping your credit card at Starbucks.

Duty-Hour Restrictions: Harbinger of The Future?

“Don’t begrudge the ACGME—begrudge us.”

—Jeff Wiese, MD, SFHM, SHM past president

In a much-anticipated session on the impact of the new ACGME residency work-hour rules commencing in July—notably limiting intern (16-hour) and resident (28-hour) shift duration—Dr. Wiese aptly pointed out that a lot of the angst toward residency work environment regulation could have been avoided if physician leadership had better reacted to the issues of sleep deprivation and resident fatigue following Libby Zion’s death in 1984. Had we put our energy into improving work conditions rather than debate the impact of sleep deprivation on the outcome in this one case, we might be in a different place today.

I couldn’t help but wonder if the message here could also be applied to society’s push for higher quality, lower cost, and safer care. Either we regulate ourselves or someone else will. In other words, we need to embrace quality and safety, or it will be thrust upon us from external sources in ways we might not like.

A Mariner Calls

“I love you, Papi. Come home and take some baseball cuts.”

—Greyson Glasheen, future Major League Baseball shortstop

I wrote in a column leading up to the annual meeting (see “Annual Meeting Mariner,” April 2011, p. 45) that I was looking forward to the meeting because it was a professional mariner of sorts, a way for me to refresh, reset, and reinvigorate. Indeed, reflecting from the podium, it had been a fantastic meeting that served its purpose well. I had learned a ton, caught up with colleagues I hadn’t seen since the last meeting, saw old medical school friends, and met future old friends. I’d led a committee, given a talk, presented a poster, met up with a mentor, and had a reunion with past attendees of the Academic Hospitalist Academy.

Yet I was ready to get back to normalcy. On the last night of the meeting, I was therefore drawn by a different, more personal mariner—this time, a 14-second voicemail message from a 3-year-old boy waiting impatiently for Dad to come home, to make him his center, to simply play a little tee ball in the backyard. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

I stare; a brimming audience stares back. Two eyeballs battling thousands. Slightly uncomfortable, I shift my weight, trying to hide behind the glass podium. Two microphones snake out of the podium slithering together inches from my mouth. The attendees squirm, sidle to the edge of their seats, restless to depart. HM11 is trying to close; only I stand in its way.

A Herculean task lies before me—summarize the annual meeting in a 10-minute wrap-up session titled “What We’ve Learned.” How do you summarize four days, eight pre-courses, nine breakout tracks, and more than 100 presentations in a few minutes? A bead of forehead sweat forms; I clear my throat. Memories of the past few days slide-show across my mind. It occurs to me that the essence of the meeting is not contained in the data, the information, or the PowerPoint slides that were presented. Rather, the story of HM11 is best told through its quotes.

Patient Caps: Your Grandmother and Professionalism

“I worry about patient caps because the next patient could be your grandmother.”

—Joe Li, MD, SFHM, new president of SHM

“Patient caps are the greatest threat to the professionalism of the field.”

—Rob Bessler, MD, CEO, Sound Inpatient Physicians

These two quotes from the opening plenary focused on the 2011 HM compensation and productivity survey particularly stuck out. The most noteworthy exchange came when Drs. Li and Bressler commented on the appropriate number of daily encounters for a hospitalist. The quotes highlight two important points about patient volume, especially in the wake of the training regulations that limit the number of resident physician encounters, which can engender a “cap mentality.” One is that it matters; there is a safe amount of encounters that shouldn’t routinely be breached. Two is that in the heat of the moment, Patient 19 is as important as Patient 11 and should be treated as such. Contingency plans are essential, but our field is built on the moorings of professionalism—the focus needs to be on humans, not numbers.

Hospitalist Compensation: Increasing but Not as Juicy

“It’s not going to get less anytime soon.”

—Dr. Bressler

In commenting on the data showing that the average community hospitalist makes about $220,000 annually—a 3% increase over last year—while producing around 4,000 work RVUs—flat over last year—and that their academic counterparts made $173,000 on about 3,400 wRVUs, Dr. Bressler opined that the laws of supply and demand would dictate that salaries would continue to rise for the near term. Although I agree with Dr. Bressler, my guess is that future salary increases will be driven more by quality than quantity (more to follow below).

“Juice-to-squeeze ratio”

—John Nelson, MD, MHM, SHM cofounder

Dr. Nelson highlighted interesting data showing that the average pay per wRVU was approximately $54. However, he noted that the compensation per wRVU tends to peak at a certain level, after which compensation per wRVU falls. In other words, after, say, 4,000 wRVUs, the amount of compensation per wRVU diminishes such that seeing more patients benefits an individual hospitalist less. That is, lots of squeeze, little juice at the high end.

Reform: Variety, Change, and Waste

“Variety is about choice; change is not.”

—Cecil Wilson, MD, AMA president

“You won’t have many more conferences where you start by talking about work RVUs.”

—Bob Kocher, MD, former special assistant to President Obama

The highlight of the conference for me was Dr. Kocher’s behind-the-scenes look at what was a very publicly muddy event—the passage of ACA. Coming from a D.C. insider, this under-the-covers peek at the machinations that went into passing the healthcare reform bill was fascinating.

The key message, summarized in this comment referring to the opening plenary about hospitalist compensation and productivity, was that the future is quality and the future is now. In the very near future, we will be measured and paid based on our ability to effect quality outcomes, not patient encounters. The message was simple: It’s about quality, not quantity.

“It costs $7.50 for a healthcare transaction, versus 2 cents for a VISA transaction.”

—Dr. Kocher

A statistic I had not heard before, this quote sums up one of the major problems with American healthcare: waste. The $7.50 transaction he was referring to was the amount of money it takes to file a healthcare claim. We certainly feel it in the challenges of documentation, billing, and denials, but the system feels it in terms of high cost of capturing what in many ways should be as simple as swiping your credit card at Starbucks.

Duty-Hour Restrictions: Harbinger of The Future?

“Don’t begrudge the ACGME—begrudge us.”

—Jeff Wiese, MD, SFHM, SHM past president

In a much-anticipated session on the impact of the new ACGME residency work-hour rules commencing in July—notably limiting intern (16-hour) and resident (28-hour) shift duration—Dr. Wiese aptly pointed out that a lot of the angst toward residency work environment regulation could have been avoided if physician leadership had better reacted to the issues of sleep deprivation and resident fatigue following Libby Zion’s death in 1984. Had we put our energy into improving work conditions rather than debate the impact of sleep deprivation on the outcome in this one case, we might be in a different place today.

I couldn’t help but wonder if the message here could also be applied to society’s push for higher quality, lower cost, and safer care. Either we regulate ourselves or someone else will. In other words, we need to embrace quality and safety, or it will be thrust upon us from external sources in ways we might not like.

A Mariner Calls

“I love you, Papi. Come home and take some baseball cuts.”

—Greyson Glasheen, future Major League Baseball shortstop

I wrote in a column leading up to the annual meeting (see “Annual Meeting Mariner,” April 2011, p. 45) that I was looking forward to the meeting because it was a professional mariner of sorts, a way for me to refresh, reset, and reinvigorate. Indeed, reflecting from the podium, it had been a fantastic meeting that served its purpose well. I had learned a ton, caught up with colleagues I hadn’t seen since the last meeting, saw old medical school friends, and met future old friends. I’d led a committee, given a talk, presented a poster, met up with a mentor, and had a reunion with past attendees of the Academic Hospitalist Academy.

Yet I was ready to get back to normalcy. On the last night of the meeting, I was therefore drawn by a different, more personal mariner—this time, a 14-second voicemail message from a 3-year-old boy waiting impatiently for Dad to come home, to make him his center, to simply play a little tee ball in the backyard. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

I stare; a brimming audience stares back. Two eyeballs battling thousands. Slightly uncomfortable, I shift my weight, trying to hide behind the glass podium. Two microphones snake out of the podium slithering together inches from my mouth. The attendees squirm, sidle to the edge of their seats, restless to depart. HM11 is trying to close; only I stand in its way.

A Herculean task lies before me—summarize the annual meeting in a 10-minute wrap-up session titled “What We’ve Learned.” How do you summarize four days, eight pre-courses, nine breakout tracks, and more than 100 presentations in a few minutes? A bead of forehead sweat forms; I clear my throat. Memories of the past few days slide-show across my mind. It occurs to me that the essence of the meeting is not contained in the data, the information, or the PowerPoint slides that were presented. Rather, the story of HM11 is best told through its quotes.

Patient Caps: Your Grandmother and Professionalism

“I worry about patient caps because the next patient could be your grandmother.”

—Joe Li, MD, SFHM, new president of SHM

“Patient caps are the greatest threat to the professionalism of the field.”

—Rob Bessler, MD, CEO, Sound Inpatient Physicians

These two quotes from the opening plenary focused on the 2011 HM compensation and productivity survey particularly stuck out. The most noteworthy exchange came when Drs. Li and Bressler commented on the appropriate number of daily encounters for a hospitalist. The quotes highlight two important points about patient volume, especially in the wake of the training regulations that limit the number of resident physician encounters, which can engender a “cap mentality.” One is that it matters; there is a safe amount of encounters that shouldn’t routinely be breached. Two is that in the heat of the moment, Patient 19 is as important as Patient 11 and should be treated as such. Contingency plans are essential, but our field is built on the moorings of professionalism—the focus needs to be on humans, not numbers.

Hospitalist Compensation: Increasing but Not as Juicy

“It’s not going to get less anytime soon.”

—Dr. Bressler

In commenting on the data showing that the average community hospitalist makes about $220,000 annually—a 3% increase over last year—while producing around 4,000 work RVUs—flat over last year—and that their academic counterparts made $173,000 on about 3,400 wRVUs, Dr. Bressler opined that the laws of supply and demand would dictate that salaries would continue to rise for the near term. Although I agree with Dr. Bressler, my guess is that future salary increases will be driven more by quality than quantity (more to follow below).

“Juice-to-squeeze ratio”

—John Nelson, MD, MHM, SHM cofounder

Dr. Nelson highlighted interesting data showing that the average pay per wRVU was approximately $54. However, he noted that the compensation per wRVU tends to peak at a certain level, after which compensation per wRVU falls. In other words, after, say, 4,000 wRVUs, the amount of compensation per wRVU diminishes such that seeing more patients benefits an individual hospitalist less. That is, lots of squeeze, little juice at the high end.

Reform: Variety, Change, and Waste

“Variety is about choice; change is not.”

—Cecil Wilson, MD, AMA president

“You won’t have many more conferences where you start by talking about work RVUs.”

—Bob Kocher, MD, former special assistant to President Obama

The highlight of the conference for me was Dr. Kocher’s behind-the-scenes look at what was a very publicly muddy event—the passage of ACA. Coming from a D.C. insider, this under-the-covers peek at the machinations that went into passing the healthcare reform bill was fascinating.

The key message, summarized in this comment referring to the opening plenary about hospitalist compensation and productivity, was that the future is quality and the future is now. In the very near future, we will be measured and paid based on our ability to effect quality outcomes, not patient encounters. The message was simple: It’s about quality, not quantity.

“It costs $7.50 for a healthcare transaction, versus 2 cents for a VISA transaction.”

—Dr. Kocher

A statistic I had not heard before, this quote sums up one of the major problems with American healthcare: waste. The $7.50 transaction he was referring to was the amount of money it takes to file a healthcare claim. We certainly feel it in the challenges of documentation, billing, and denials, but the system feels it in terms of high cost of capturing what in many ways should be as simple as swiping your credit card at Starbucks.

Duty-Hour Restrictions: Harbinger of The Future?

“Don’t begrudge the ACGME—begrudge us.”

—Jeff Wiese, MD, SFHM, SHM past president

In a much-anticipated session on the impact of the new ACGME residency work-hour rules commencing in July—notably limiting intern (16-hour) and resident (28-hour) shift duration—Dr. Wiese aptly pointed out that a lot of the angst toward residency work environment regulation could have been avoided if physician leadership had better reacted to the issues of sleep deprivation and resident fatigue following Libby Zion’s death in 1984. Had we put our energy into improving work conditions rather than debate the impact of sleep deprivation on the outcome in this one case, we might be in a different place today.

I couldn’t help but wonder if the message here could also be applied to society’s push for higher quality, lower cost, and safer care. Either we regulate ourselves or someone else will. In other words, we need to embrace quality and safety, or it will be thrust upon us from external sources in ways we might not like.

A Mariner Calls

“I love you, Papi. Come home and take some baseball cuts.”

—Greyson Glasheen, future Major League Baseball shortstop

I wrote in a column leading up to the annual meeting (see “Annual Meeting Mariner,” April 2011, p. 45) that I was looking forward to the meeting because it was a professional mariner of sorts, a way for me to refresh, reset, and reinvigorate. Indeed, reflecting from the podium, it had been a fantastic meeting that served its purpose well. I had learned a ton, caught up with colleagues I hadn’t seen since the last meeting, saw old medical school friends, and met future old friends. I’d led a committee, given a talk, presented a poster, met up with a mentor, and had a reunion with past attendees of the Academic Hospitalist Academy.

Yet I was ready to get back to normalcy. On the last night of the meeting, I was therefore drawn by a different, more personal mariner—this time, a 14-second voicemail message from a 3-year-old boy waiting impatiently for Dad to come home, to make him his center, to simply play a little tee ball in the backyard. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

Eight glorious months ago, my wife, Bridget, and I went to the hospital for the birth of our daughter, Livia. I remember the night clearly. It was a planned induction. Labor and delivery was quite busy, so we spent a few hours in the waiting area before our room was ready. Prominently displayed, a royal blue banner and crystal piece announced a Codman Award from the Joint Commission. Presented to only a few healthcare champions annually, this award represented a significant achievement in birth safety. I was proud to have Bridget (and Livia) there.

But had it not been for the Institute for Healthcare Improvement (IHI) Annual Forum’s plenary sessions earlier that year, I probably would have ignored the flashy cabinet, mistaking it for propaganda or a feel-good award that everyone receives if they are nice to Joint Commission inspectors. As it were, I recalled the IHI panel discussion where I had first heard the CEO of Seton Family of Hospitals describe dramatic reductions in the network’s rates of birth injury. Most contentious had been the elimination of elective labor inductions and C-sections at our hospitals before 39 weeks’ gestation.

Perhaps understandably, Bridget was not distracted by any of this. Eyes closed, she was trying to make it through one last uncomfortable night while resting sideways on four chairs pushed together. I knew better than to force the conversation. Two weeks earlier, we had a heated discussion about whether there was any reason to induce earlier for convenience (i.e. obstetrician and grandparents-to-be schedules).

A few months later, at a meeting of physician leadership in our network, the question of whether doctors could lead transformative improvements in care in our community was raised. Thinking back to the Codman Award, I asked an obstetrician if the birth-safety initiative had increased the leadership capacity of physicians.

The reply was quick. “Not really,” she said. “The physicians felt like they were just following some rules.”

Rules? Nobody wanted to bask in the glory of a project that greatly improved outcomes and reduced costs? As I sat in silence and tried to absorb the significance of the response, I was hit from the right with another revelation. A hospital executive in the group noted that this was a very unpopular initiative amongst administrators. There were now fewer feeders and growers populating our NICUs, and this significantly and negatively impacted the bottom line of the hospitals. NICU reimbursement, of course, is a cash cow.

Thus, it came as no surprise when my editor forwarded a recent New York Times piece (www.nytimes.com/2011/03/20/us/20ttnicus.html) on this very issue of overuse in NICU care. The article even profiled my hospital network in Austin, Texas. The drama in the story was the millions of dollars lost by hospitals, potential Texas Medicaid crackdowns on NICU care, and the move away from convenience care.

But a much more important point was missed … value.

The Only Goal

Simply stated, value in healthcare is quality outcomes divided by total costs of care. The real storyline here is that a multidisciplinary team within Seton has greatly improved the single most important metric in healthcare—value. The numerator is healthy deliveries. The denominator is total costs of care. Quality outcomes will drive costs lower, and maximizing this equation should be the only goal we work toward. And yet, routine discussions of how we achieve value are all but absent in our daily conversations.

I suppose it’s only natural that we are distracted. The media will always focus on the dramatic aspect of the story. Political strategists spend days in fluorescently lit rooms devising new ways to keep us misdirected (think death panels). Our academic research agenda continues to prioritize technological advances over efficient healthcare delivery. And our fragmented payment systems all but guarantee that care providers will waste their time on the wrong financial analyses. “Perverse” is an oft-used term to describe our reimbursement system; it aptly describes my experience with “performance” data. How is it that I am regularly subjected to financial reports detailing every bit of billing and coding minutiae, but it takes an act of Congress for me to find simple clinical outcomes data, let alone costs of care? Value is the forgotten stepchild of healthcare reform rhetoric.

Thus, the publicizing of overuse in NICUs is a microcosm of the quagmire that we find ourselves in today. Healthcare spending is a tsunami projected to devastate the shores of our national economy in as little as five years. In the shadow of this rapidly receding financial wave, competing interest groups stand barefoot on the beach debating whether the clinical waste surrounding us is really pollution (one person’s waste is another’s income, as the saying goes). It’s as if we’re all frozen by the spectacle, unable to move toward higher-level value solutions.

All sides will agree, however, that we are quickly running out of time. Continued inaction will condemn us to a crash financial evacuation of cholera-like proportions.

Simple Solution: HM

How do we avert such a natural disaster? I see front-line clinicians—yes, hospitalists—leading the way. Hospitals and healthcare networks are actively mobilizing to create accountable-care organizations (ACOs) in preparation for payment reform almost certain to resurrect some form of capitation or bundling. The finance department of these organizations can only do so much. As they feel the tremors of financial instability, they will cling to what they know—increasing revenue through new services and budget line-item reductions (e.g. decreased funding for hospitalists).

These are short-term solutions at best, and your HM group might already be experiencing the after-effects of such activity.

Hospital administrators will tighten the financial belts, but they cannot improve clinical quality by reducing waste. To paraphrase Atul Gawande, doctors must cap their own pens if we are to reduce waste in the system. Value, then, can only be defined at the bedside in the context of a healthy physician-patient relationship. And as hospitalists, we are at the bedside of the most expensive decisions in medicine.

Although the future landscape might seem bleak, opportunities for HM are aglow with promise. We have the best view of how the system might make the biggest gains. We have been raised with a focus on quality. Scores of improvement success stories are told annually at our national meetings. If we can shift our conversations to improving quality while lowering costs, I believe that defining value will prove to be our field of dreams. TH

Dr. Shen is medical director of hospital medicine at Dell Children’s Hospital in Austin, Texas, and The Hospitalist’s pediatric editor.

Eight glorious months ago, my wife, Bridget, and I went to the hospital for the birth of our daughter, Livia. I remember the night clearly. It was a planned induction. Labor and delivery was quite busy, so we spent a few hours in the waiting area before our room was ready. Prominently displayed, a royal blue banner and crystal piece announced a Codman Award from the Joint Commission. Presented to only a few healthcare champions annually, this award represented a significant achievement in birth safety. I was proud to have Bridget (and Livia) there.

But had it not been for the Institute for Healthcare Improvement (IHI) Annual Forum’s plenary sessions earlier that year, I probably would have ignored the flashy cabinet, mistaking it for propaganda or a feel-good award that everyone receives if they are nice to Joint Commission inspectors. As it were, I recalled the IHI panel discussion where I had first heard the CEO of Seton Family of Hospitals describe dramatic reductions in the network’s rates of birth injury. Most contentious had been the elimination of elective labor inductions and C-sections at our hospitals before 39 weeks’ gestation.

Perhaps understandably, Bridget was not distracted by any of this. Eyes closed, she was trying to make it through one last uncomfortable night while resting sideways on four chairs pushed together. I knew better than to force the conversation. Two weeks earlier, we had a heated discussion about whether there was any reason to induce earlier for convenience (i.e. obstetrician and grandparents-to-be schedules).

A few months later, at a meeting of physician leadership in our network, the question of whether doctors could lead transformative improvements in care in our community was raised. Thinking back to the Codman Award, I asked an obstetrician if the birth-safety initiative had increased the leadership capacity of physicians.

The reply was quick. “Not really,” she said. “The physicians felt like they were just following some rules.”

Rules? Nobody wanted to bask in the glory of a project that greatly improved outcomes and reduced costs? As I sat in silence and tried to absorb the significance of the response, I was hit from the right with another revelation. A hospital executive in the group noted that this was a very unpopular initiative amongst administrators. There were now fewer feeders and growers populating our NICUs, and this significantly and negatively impacted the bottom line of the hospitals. NICU reimbursement, of course, is a cash cow.

Thus, it came as no surprise when my editor forwarded a recent New York Times piece (www.nytimes.com/2011/03/20/us/20ttnicus.html) on this very issue of overuse in NICU care. The article even profiled my hospital network in Austin, Texas. The drama in the story was the millions of dollars lost by hospitals, potential Texas Medicaid crackdowns on NICU care, and the move away from convenience care.

But a much more important point was missed … value.

The Only Goal

Simply stated, value in healthcare is quality outcomes divided by total costs of care. The real storyline here is that a multidisciplinary team within Seton has greatly improved the single most important metric in healthcare—value. The numerator is healthy deliveries. The denominator is total costs of care. Quality outcomes will drive costs lower, and maximizing this equation should be the only goal we work toward. And yet, routine discussions of how we achieve value are all but absent in our daily conversations.

I suppose it’s only natural that we are distracted. The media will always focus on the dramatic aspect of the story. Political strategists spend days in fluorescently lit rooms devising new ways to keep us misdirected (think death panels). Our academic research agenda continues to prioritize technological advances over efficient healthcare delivery. And our fragmented payment systems all but guarantee that care providers will waste their time on the wrong financial analyses. “Perverse” is an oft-used term to describe our reimbursement system; it aptly describes my experience with “performance” data. How is it that I am regularly subjected to financial reports detailing every bit of billing and coding minutiae, but it takes an act of Congress for me to find simple clinical outcomes data, let alone costs of care? Value is the forgotten stepchild of healthcare reform rhetoric.

Thus, the publicizing of overuse in NICUs is a microcosm of the quagmire that we find ourselves in today. Healthcare spending is a tsunami projected to devastate the shores of our national economy in as little as five years. In the shadow of this rapidly receding financial wave, competing interest groups stand barefoot on the beach debating whether the clinical waste surrounding us is really pollution (one person’s waste is another’s income, as the saying goes). It’s as if we’re all frozen by the spectacle, unable to move toward higher-level value solutions.

All sides will agree, however, that we are quickly running out of time. Continued inaction will condemn us to a crash financial evacuation of cholera-like proportions.

Simple Solution: HM

How do we avert such a natural disaster? I see front-line clinicians—yes, hospitalists—leading the way. Hospitals and healthcare networks are actively mobilizing to create accountable-care organizations (ACOs) in preparation for payment reform almost certain to resurrect some form of capitation or bundling. The finance department of these organizations can only do so much. As they feel the tremors of financial instability, they will cling to what they know—increasing revenue through new services and budget line-item reductions (e.g. decreased funding for hospitalists).

These are short-term solutions at best, and your HM group might already be experiencing the after-effects of such activity.

Hospital administrators will tighten the financial belts, but they cannot improve clinical quality by reducing waste. To paraphrase Atul Gawande, doctors must cap their own pens if we are to reduce waste in the system. Value, then, can only be defined at the bedside in the context of a healthy physician-patient relationship. And as hospitalists, we are at the bedside of the most expensive decisions in medicine.

Although the future landscape might seem bleak, opportunities for HM are aglow with promise. We have the best view of how the system might make the biggest gains. We have been raised with a focus on quality. Scores of improvement success stories are told annually at our national meetings. If we can shift our conversations to improving quality while lowering costs, I believe that defining value will prove to be our field of dreams. TH

Dr. Shen is medical director of hospital medicine at Dell Children’s Hospital in Austin, Texas, and The Hospitalist’s pediatric editor.

Eight glorious months ago, my wife, Bridget, and I went to the hospital for the birth of our daughter, Livia. I remember the night clearly. It was a planned induction. Labor and delivery was quite busy, so we spent a few hours in the waiting area before our room was ready. Prominently displayed, a royal blue banner and crystal piece announced a Codman Award from the Joint Commission. Presented to only a few healthcare champions annually, this award represented a significant achievement in birth safety. I was proud to have Bridget (and Livia) there.

But had it not been for the Institute for Healthcare Improvement (IHI) Annual Forum’s plenary sessions earlier that year, I probably would have ignored the flashy cabinet, mistaking it for propaganda or a feel-good award that everyone receives if they are nice to Joint Commission inspectors. As it were, I recalled the IHI panel discussion where I had first heard the CEO of Seton Family of Hospitals describe dramatic reductions in the network’s rates of birth injury. Most contentious had been the elimination of elective labor inductions and C-sections at our hospitals before 39 weeks’ gestation.

Perhaps understandably, Bridget was not distracted by any of this. Eyes closed, she was trying to make it through one last uncomfortable night while resting sideways on four chairs pushed together. I knew better than to force the conversation. Two weeks earlier, we had a heated discussion about whether there was any reason to induce earlier for convenience (i.e. obstetrician and grandparents-to-be schedules).

A few months later, at a meeting of physician leadership in our network, the question of whether doctors could lead transformative improvements in care in our community was raised. Thinking back to the Codman Award, I asked an obstetrician if the birth-safety initiative had increased the leadership capacity of physicians.

The reply was quick. “Not really,” she said. “The physicians felt like they were just following some rules.”

Rules? Nobody wanted to bask in the glory of a project that greatly improved outcomes and reduced costs? As I sat in silence and tried to absorb the significance of the response, I was hit from the right with another revelation. A hospital executive in the group noted that this was a very unpopular initiative amongst administrators. There were now fewer feeders and growers populating our NICUs, and this significantly and negatively impacted the bottom line of the hospitals. NICU reimbursement, of course, is a cash cow.

Thus, it came as no surprise when my editor forwarded a recent New York Times piece (www.nytimes.com/2011/03/20/us/20ttnicus.html) on this very issue of overuse in NICU care. The article even profiled my hospital network in Austin, Texas. The drama in the story was the millions of dollars lost by hospitals, potential Texas Medicaid crackdowns on NICU care, and the move away from convenience care.

But a much more important point was missed … value.

The Only Goal

Simply stated, value in healthcare is quality outcomes divided by total costs of care. The real storyline here is that a multidisciplinary team within Seton has greatly improved the single most important metric in healthcare—value. The numerator is healthy deliveries. The denominator is total costs of care. Quality outcomes will drive costs lower, and maximizing this equation should be the only goal we work toward. And yet, routine discussions of how we achieve value are all but absent in our daily conversations.

I suppose it’s only natural that we are distracted. The media will always focus on the dramatic aspect of the story. Political strategists spend days in fluorescently lit rooms devising new ways to keep us misdirected (think death panels). Our academic research agenda continues to prioritize technological advances over efficient healthcare delivery. And our fragmented payment systems all but guarantee that care providers will waste their time on the wrong financial analyses. “Perverse” is an oft-used term to describe our reimbursement system; it aptly describes my experience with “performance” data. How is it that I am regularly subjected to financial reports detailing every bit of billing and coding minutiae, but it takes an act of Congress for me to find simple clinical outcomes data, let alone costs of care? Value is the forgotten stepchild of healthcare reform rhetoric.

Thus, the publicizing of overuse in NICUs is a microcosm of the quagmire that we find ourselves in today. Healthcare spending is a tsunami projected to devastate the shores of our national economy in as little as five years. In the shadow of this rapidly receding financial wave, competing interest groups stand barefoot on the beach debating whether the clinical waste surrounding us is really pollution (one person’s waste is another’s income, as the saying goes). It’s as if we’re all frozen by the spectacle, unable to move toward higher-level value solutions.

All sides will agree, however, that we are quickly running out of time. Continued inaction will condemn us to a crash financial evacuation of cholera-like proportions.

Simple Solution: HM

How do we avert such a natural disaster? I see front-line clinicians—yes, hospitalists—leading the way. Hospitals and healthcare networks are actively mobilizing to create accountable-care organizations (ACOs) in preparation for payment reform almost certain to resurrect some form of capitation or bundling. The finance department of these organizations can only do so much. As they feel the tremors of financial instability, they will cling to what they know—increasing revenue through new services and budget line-item reductions (e.g. decreased funding for hospitalists).

These are short-term solutions at best, and your HM group might already be experiencing the after-effects of such activity.

Hospital administrators will tighten the financial belts, but they cannot improve clinical quality by reducing waste. To paraphrase Atul Gawande, doctors must cap their own pens if we are to reduce waste in the system. Value, then, can only be defined at the bedside in the context of a healthy physician-patient relationship. And as hospitalists, we are at the bedside of the most expensive decisions in medicine.

Although the future landscape might seem bleak, opportunities for HM are aglow with promise. We have the best view of how the system might make the biggest gains. We have been raised with a focus on quality. Scores of improvement success stories are told annually at our national meetings. If we can shift our conversations to improving quality while lowering costs, I believe that defining value will prove to be our field of dreams. TH

Dr. Shen is medical director of hospital medicine at Dell Children’s Hospital in Austin, Texas, and The Hospitalist’s pediatric editor.