When Tait Shanafelt, MD, and his colleagues at the Mayo Clinic in Rochester, Minn., investigated whether medical residents who rated high on burnout also delivered lower quality care, they found an interesting correlation: Physicians who reported errors experienced more burnout, and burned-out physicians made more errors.1

“While the patient safety issue is paramount, there is also a pretty substantial personal cost to physicians when they perceive that they have made an error,” says Dr. Shanafelt, an assistant professor of medicine.

Whether or not a bad outcome stems from “errors,” hospitalists may experience a psychoemotional aftermath. They often suffer in silence, imagining that few other doctors make errors. This common experience has historically been covered by a veil of silence.2

Silent Struggle

Caregivers are largely hesitant to discuss their involvement in adverse events.

“Their reluctance to discuss this with their colleagues is a common barrier to work through this in constructive ways,” Dr. Shanafelt says.

Though clinical decisions have systems and individual components, when mistakes happen it’s the latter with which hospitalists struggle silently—and often dysfunctionally.

“Every serious adverse event has at least two victims: the patient and family; and the caregiver,” says Albert W. Wu, MD, a professor of health policy and management at Johns Hopkins University in Baltimore.3-5

Although there is merit in analyzing the mistake and learning from it, doing so without facing the personal consequences is insufficient.

“Even if there was a system factor that can be identified, physicians still feel personally responsible for their patients and they often carry a sense of guilt around with them,” Dr. Shanafelt says.

That feeling of responsibility is not necessarily a bad thing.

“It is important to recognize that everything is not a systems error,” says Lenny Feldman, MD, an assistant professor and hospitalist with the Division of General Internal Medicine at Johns Hopkins Hospital. “Individuals want to be able to take responsibility for the bad things that have happened, and there is a value to that.”

The medical profession has just begun to fully acknowledge the inevitability of errors and the need for clinicians to be trained to manage them. Emotional responses to bad outcomes or medical errors include fear, guilt, anger, embarrassment, humiliation, and depression, which can last days—or years.

“The cognoscenti of coping know that there are adaptive and maladaptive ways of coping,” says Dr. Wu. “Adaptive would be reframing and growing and learning from the incident, channeling the energy into trying to do better next time. Maladaptive strategies include denial, turning to alcohol, and becoming angry.”

What Hospitalists Can Do

Healthcare is changing its culture so reporting adverse events is easier, without an emphasis on assigning blame.

Support is available by phone, disclosure protocols have been created, and practitioners work with risk management personnel to involve patients and families in discussions and apologies. These processes can give physicians a healthy way to be transparent about what happened and also to know that their institutions support them.

Mixed emotions are common after a bad choice or outcome, but the stakes are particularly high in hospital-based specialties.

“Physicians who practice in hospitals are at particular risk for being involved in instances where patients are harmed, partly because of the acuity of patients and partly because they are repeatedly in this environment,” Dr. Wu says. “In a way, for some physicians and nurses, it is like working in a war zone. It is necessary for you to return to that zone to work, even after something bad happens. That, in itself, can be traumatic.”

Experts accentuate the importance of providing hospitalists, especially young ones, the tools to help them recognize and manage post-event emotional baggage. These tools can serve as a roadmap on how to work through their experience.

Periodic debriefing with peers helps hospitalists discuss what’s going on in their practice. But if a hospitalist has not established this trust and support beforehand, it may be difficult to locate the right support after an event occurs.

“There is a healing that goes on when you are able to share with your colleagues who can tell you about their own experiences with this,” says Dr. Shanafelt.

Dr. Feldman agrees. After a couple of bad patient outcomes this year, he needed to talk as much as possible in a few forums, including with his hospitalist group leader and his peers. As the associate program director at his institution, he also checked in with his residents.

“I know how I’m feeling, which is horrible,” Dr. Feldman says. “You know if you’re doing it, your residents are probably doing the same thing.”

Teaching hospitalists can help change the culture by making them willing to share their own experiences with trainees.

“For supervising physicians to say, in effect, to medical students and residents, ‘In my own career, these are things I have experienced and how I’ve worked through them,’ can help young physicians recognize that identifying and working though the consequences of errors on both a professional and personal level is an important part of being a mindful physician,” says Dr. Shanafelt.

Open and humble sharing means trainees can act similarly.

“When we were first presenting our data to the residents in one of our early studies, I often felt like a priest with physicians coming me to confess their mistakes,” Dr. Shanafelt says. “After having this experience repeat itself over and over, I recognized that sharing this was a cathartic event for them.”

The most helpful thing hospitalists can do for each other is listen without judgment.

“We need to realize it is going to happen to each and every one of us, and be prepared to offer a shoulder to cry on to help your colleague work through it,” says Dr. Feldman.

Dr. Wu believes clinicians need to examine their capacity to offer such support.

“We are not as reassuring as we could be,” Dr. Wu says. “I think we tend to hold back, maybe because we are so fearful of the whole idea. Really admitting that this is a normal, common event frightens us too much.”

What Hospitalist Groups Can Do

Cleo Hardin, MD, section chief of pediatric hospital medicine at the University of Arizona in Tucson, says her department deals with post-event distress several ways. Her doctors talk with her, share in their departmental morbidity and mortality conference, and don’t ignore errors and bad outcomes.

“Anytime there is a bad outcome,” Dr. Hardin says, “it is very important for the leader of the group to meet with the individual to ask, ‘What do we need to do to reduce the likelihood that you’re going to develop post-traumatic stress disorder and that you’re going to question everything you do in the future? You are a good doctor. How do we keep you being a good doctor?’ ”

A show of support by the whole team is of utmost importance.

“There is a tremendous amount of camaraderie in the group, and we all understand [that clinical practice] is not an exact science,” Dr. Hardin says. “There’s a lot of art in medicine.”

An expression of that art showed up several years ago in her hospital’s pediatrics unit when a child died on Christmas Day.

“On the day an event happens, I think the person is reeling and in shock and can’t hear anything,” Dr. Hardin says. “I called the hospitalist to ask whether he needed coverage. He declined, saying he was afraid if he got off the horse, he would never get back on.”

The following month they discussed the event at their mortality and morbidity conference; the entire hospitalist section was there.

“We sat together, and it was very clear to the hospitalist involved in the event that he was not there alone,” Dr. Hardin says. “We told him how much we appreciated him and respected him, and we were there to be his support.”

What Leaders Can Do

As the director of the hospitalist program at Johns Hopkins Hospital, Daniel J. Brotman, MD, FACP, understands that the level of upset after a bad outcome can be dramatic.

“Whether or not it was your fault, and independent of any medical-legal ramifications, although those certainly exist,” he says, “there’s a personal sense of just being a human being; of wanting to go back; questioning whether you made a right decision, a wrong decision; and facing whether you would change anything if you could do it again.”

Dr. Brotman believes in leading by example. “What you want is an open-door policy where faculty members can say, ‘Something bad happened, I need to get it off my chest, and I need to do it now,’” he says.

The group leader also needs to know what happened in case there’s a need for damage control beyond the hospitalist group. The leader should ultimately be the one who confers forgiveness.

“If somebody feels they are keeping a secret, it’s going to make matters worse,” Dr. Brotman says.

Research confirms the needs for “confession, restitution, and absolution,” and hospitalists need their competence validated.6

Even though I [have been] honest and said, ‘I don’t think I would have made that decision,’ I also have said, ‘I know that in terms of your thought process, you were acting in the best interest of the patient … and you’re one of the most compassionate physicians I know,” Dr. Brotman says.

As leaders gather information on an adverse event, they may also be in a better position to advocate for the hospitalist in subsequent conversations. In so doing, they can save that individual further embarrassment and humiliation.

“I hope that I’m able to process what I was experiencing in a way that doesn’t paralyze me,” Dr. Feldman says. “But I hope it informs me to the gravity of the situation.” TH

Andrea Sattinger is a medical writer based in North Carolina.

References

1. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078.
2. Goldberg RM, Kuhn G, Andrew LB, et al. Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002;39(3):287-292.
3. Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999;131(12):970-972.
4. Wu AW. Medical error: the second victim. BMJ. 2000;320(7237):726-727.
5. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265(16):2089-2094.
6. Wears RL, Wu AW. Dealing with failure: the aftermath of errors and adverse events. Ann Emerg Med. 2002;39(3):344-346.

When Tait Shanafelt, MD, and his colleagues at the Mayo Clinic in Rochester, Minn., investigated whether medical residents who rated high on burnout also delivered lower quality care, they found an interesting correlation: Physicians who reported errors experienced more burnout, and burned-out physicians made more errors.1

“While the patient safety issue is paramount, there is also a pretty substantial personal cost to physicians when they perceive that they have made an error,” says Dr. Shanafelt, an assistant professor of medicine.

Whether or not a bad outcome stems from “errors,” hospitalists may experience a psychoemotional aftermath. They often suffer in silence, imagining that few other doctors make errors. This common experience has historically been covered by a veil of silence.2

Silent Struggle

Caregivers are largely hesitant to discuss their involvement in adverse events.

“Their reluctance to discuss this with their colleagues is a common barrier to work through this in constructive ways,” Dr. Shanafelt says.

Though clinical decisions have systems and individual components, when mistakes happen it’s the latter with which hospitalists struggle silently—and often dysfunctionally.

“Every serious adverse event has at least two victims: the patient and family; and the caregiver,” says Albert W. Wu, MD, a professor of health policy and management at Johns Hopkins University in Baltimore.3-5

Although there is merit in analyzing the mistake and learning from it, doing so without facing the personal consequences is insufficient.

“Even if there was a system factor that can be identified, physicians still feel personally responsible for their patients and they often carry a sense of guilt around with them,” Dr. Shanafelt says.

That feeling of responsibility is not necessarily a bad thing.

“It is important to recognize that everything is not a systems error,” says Lenny Feldman, MD, an assistant professor and hospitalist with the Division of General Internal Medicine at Johns Hopkins Hospital. “Individuals want to be able to take responsibility for the bad things that have happened, and there is a value to that.”

The medical profession has just begun to fully acknowledge the inevitability of errors and the need for clinicians to be trained to manage them. Emotional responses to bad outcomes or medical errors include fear, guilt, anger, embarrassment, humiliation, and depression, which can last days—or years.

“The cognoscenti of coping know that there are adaptive and maladaptive ways of coping,” says Dr. Wu. “Adaptive would be reframing and growing and learning from the incident, channeling the energy into trying to do better next time. Maladaptive strategies include denial, turning to alcohol, and becoming angry.”

What Hospitalists Can Do

Healthcare is changing its culture so reporting adverse events is easier, without an emphasis on assigning blame.

Support is available by phone, disclosure protocols have been created, and practitioners work with risk management personnel to involve patients and families in discussions and apologies. These processes can give physicians a healthy way to be transparent about what happened and also to know that their institutions support them.

Mixed emotions are common after a bad choice or outcome, but the stakes are particularly high in hospital-based specialties.

“Physicians who practice in hospitals are at particular risk for being involved in instances where patients are harmed, partly because of the acuity of patients and partly because they are repeatedly in this environment,” Dr. Wu says. “In a way, for some physicians and nurses, it is like working in a war zone. It is necessary for you to return to that zone to work, even after something bad happens. That, in itself, can be traumatic.”

Experts accentuate the importance of providing hospitalists, especially young ones, the tools to help them recognize and manage post-event emotional baggage. These tools can serve as a roadmap on how to work through their experience.

Periodic debriefing with peers helps hospitalists discuss what’s going on in their practice. But if a hospitalist has not established this trust and support beforehand, it may be difficult to locate the right support after an event occurs.

“There is a healing that goes on when you are able to share with your colleagues who can tell you about their own experiences with this,” says Dr. Shanafelt.

Dr. Feldman agrees. After a couple of bad patient outcomes this year, he needed to talk as much as possible in a few forums, including with his hospitalist group leader and his peers. As the associate program director at his institution, he also checked in with his residents.

“I know how I’m feeling, which is horrible,” Dr. Feldman says. “You know if you’re doing it, your residents are probably doing the same thing.”

Teaching hospitalists can help change the culture by making them willing to share their own experiences with trainees.

“For supervising physicians to say, in effect, to medical students and residents, ‘In my own career, these are things I have experienced and how I’ve worked through them,’ can help young physicians recognize that identifying and working though the consequences of errors on both a professional and personal level is an important part of being a mindful physician,” says Dr. Shanafelt.

Open and humble sharing means trainees can act similarly.

“When we were first presenting our data to the residents in one of our early studies, I often felt like a priest with physicians coming me to confess their mistakes,” Dr. Shanafelt says. “After having this experience repeat itself over and over, I recognized that sharing this was a cathartic event for them.”

The most helpful thing hospitalists can do for each other is listen without judgment.

“We need to realize it is going to happen to each and every one of us, and be prepared to offer a shoulder to cry on to help your colleague work through it,” says Dr. Feldman.

Dr. Wu believes clinicians need to examine their capacity to offer such support.

“We are not as reassuring as we could be,” Dr. Wu says. “I think we tend to hold back, maybe because we are so fearful of the whole idea. Really admitting that this is a normal, common event frightens us too much.”

What Hospitalist Groups Can Do

Cleo Hardin, MD, section chief of pediatric hospital medicine at the University of Arizona in Tucson, says her department deals with post-event distress several ways. Her doctors talk with her, share in their departmental morbidity and mortality conference, and don’t ignore errors and bad outcomes.

“Anytime there is a bad outcome,” Dr. Hardin says, “it is very important for the leader of the group to meet with the individual to ask, ‘What do we need to do to reduce the likelihood that you’re going to develop post-traumatic stress disorder and that you’re going to question everything you do in the future? You are a good doctor. How do we keep you being a good doctor?’ ”

A show of support by the whole team is of utmost importance.

“There is a tremendous amount of camaraderie in the group, and we all understand [that clinical practice] is not an exact science,” Dr. Hardin says. “There’s a lot of art in medicine.”

An expression of that art showed up several years ago in her hospital’s pediatrics unit when a child died on Christmas Day.

“On the day an event happens, I think the person is reeling and in shock and can’t hear anything,” Dr. Hardin says. “I called the hospitalist to ask whether he needed coverage. He declined, saying he was afraid if he got off the horse, he would never get back on.”

The following month they discussed the event at their mortality and morbidity conference; the entire hospitalist section was there.

“We sat together, and it was very clear to the hospitalist involved in the event that he was not there alone,” Dr. Hardin says. “We told him how much we appreciated him and respected him, and we were there to be his support.”

What Leaders Can Do

As the director of the hospitalist program at Johns Hopkins Hospital, Daniel J. Brotman, MD, FACP, understands that the level of upset after a bad outcome can be dramatic.

“Whether or not it was your fault, and independent of any medical-legal ramifications, although those certainly exist,” he says, “there’s a personal sense of just being a human being; of wanting to go back; questioning whether you made a right decision, a wrong decision; and facing whether you would change anything if you could do it again.”

Dr. Brotman believes in leading by example. “What you want is an open-door policy where faculty members can say, ‘Something bad happened, I need to get it off my chest, and I need to do it now,’” he says.

The group leader also needs to know what happened in case there’s a need for damage control beyond the hospitalist group. The leader should ultimately be the one who confers forgiveness.

“If somebody feels they are keeping a secret, it’s going to make matters worse,” Dr. Brotman says.

Research confirms the needs for “confession, restitution, and absolution,” and hospitalists need their competence validated.6

Even though I [have been] honest and said, ‘I don’t think I would have made that decision,’ I also have said, ‘I know that in terms of your thought process, you were acting in the best interest of the patient … and you’re one of the most compassionate physicians I know,” Dr. Brotman says.

As leaders gather information on an adverse event, they may also be in a better position to advocate for the hospitalist in subsequent conversations. In so doing, they can save that individual further embarrassment and humiliation.

“I hope that I’m able to process what I was experiencing in a way that doesn’t paralyze me,” Dr. Feldman says. “But I hope it informs me to the gravity of the situation.” TH

Andrea Sattinger is a medical writer based in North Carolina.

References

1. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078.
2. Goldberg RM, Kuhn G, Andrew LB, et al. Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002;39(3):287-292.
3. Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999;131(12):970-972.
4. Wu AW. Medical error: the second victim. BMJ. 2000;320(7237):726-727.
5. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265(16):2089-2094.
6. Wears RL, Wu AW. Dealing with failure: the aftermath of errors and adverse events. Ann Emerg Med. 2002;39(3):344-346.

When Tait Shanafelt, MD, and his colleagues at the Mayo Clinic in Rochester, Minn., investigated whether medical residents who rated high on burnout also delivered lower quality care, they found an interesting correlation: Physicians who reported errors experienced more burnout, and burned-out physicians made more errors.1

“While the patient safety issue is paramount, there is also a pretty substantial personal cost to physicians when they perceive that they have made an error,” says Dr. Shanafelt, an assistant professor of medicine.

Whether or not a bad outcome stems from “errors,” hospitalists may experience a psychoemotional aftermath. They often suffer in silence, imagining that few other doctors make errors. This common experience has historically been covered by a veil of silence.2

Silent Struggle

Caregivers are largely hesitant to discuss their involvement in adverse events.

“Their reluctance to discuss this with their colleagues is a common barrier to work through this in constructive ways,” Dr. Shanafelt says.

Though clinical decisions have systems and individual components, when mistakes happen it’s the latter with which hospitalists struggle silently—and often dysfunctionally.

“Every serious adverse event has at least two victims: the patient and family; and the caregiver,” says Albert W. Wu, MD, a professor of health policy and management at Johns Hopkins University in Baltimore.3-5

Although there is merit in analyzing the mistake and learning from it, doing so without facing the personal consequences is insufficient.

“Even if there was a system factor that can be identified, physicians still feel personally responsible for their patients and they often carry a sense of guilt around with them,” Dr. Shanafelt says.

That feeling of responsibility is not necessarily a bad thing.

“It is important to recognize that everything is not a systems error,” says Lenny Feldman, MD, an assistant professor and hospitalist with the Division of General Internal Medicine at Johns Hopkins Hospital. “Individuals want to be able to take responsibility for the bad things that have happened, and there is a value to that.”

The medical profession has just begun to fully acknowledge the inevitability of errors and the need for clinicians to be trained to manage them. Emotional responses to bad outcomes or medical errors include fear, guilt, anger, embarrassment, humiliation, and depression, which can last days—or years.

“The cognoscenti of coping know that there are adaptive and maladaptive ways of coping,” says Dr. Wu. “Adaptive would be reframing and growing and learning from the incident, channeling the energy into trying to do better next time. Maladaptive strategies include denial, turning to alcohol, and becoming angry.”

What Hospitalists Can Do

Healthcare is changing its culture so reporting adverse events is easier, without an emphasis on assigning blame.

Support is available by phone, disclosure protocols have been created, and practitioners work with risk management personnel to involve patients and families in discussions and apologies. These processes can give physicians a healthy way to be transparent about what happened and also to know that their institutions support them.

Mixed emotions are common after a bad choice or outcome, but the stakes are particularly high in hospital-based specialties.

“Physicians who practice in hospitals are at particular risk for being involved in instances where patients are harmed, partly because of the acuity of patients and partly because they are repeatedly in this environment,” Dr. Wu says. “In a way, for some physicians and nurses, it is like working in a war zone. It is necessary for you to return to that zone to work, even after something bad happens. That, in itself, can be traumatic.”

Experts accentuate the importance of providing hospitalists, especially young ones, the tools to help them recognize and manage post-event emotional baggage. These tools can serve as a roadmap on how to work through their experience.

Periodic debriefing with peers helps hospitalists discuss what’s going on in their practice. But if a hospitalist has not established this trust and support beforehand, it may be difficult to locate the right support after an event occurs.

“There is a healing that goes on when you are able to share with your colleagues who can tell you about their own experiences with this,” says Dr. Shanafelt.

Dr. Feldman agrees. After a couple of bad patient outcomes this year, he needed to talk as much as possible in a few forums, including with his hospitalist group leader and his peers. As the associate program director at his institution, he also checked in with his residents.

“I know how I’m feeling, which is horrible,” Dr. Feldman says. “You know if you’re doing it, your residents are probably doing the same thing.”

Teaching hospitalists can help change the culture by making them willing to share their own experiences with trainees.

“For supervising physicians to say, in effect, to medical students and residents, ‘In my own career, these are things I have experienced and how I’ve worked through them,’ can help young physicians recognize that identifying and working though the consequences of errors on both a professional and personal level is an important part of being a mindful physician,” says Dr. Shanafelt.

Open and humble sharing means trainees can act similarly.

“When we were first presenting our data to the residents in one of our early studies, I often felt like a priest with physicians coming me to confess their mistakes,” Dr. Shanafelt says. “After having this experience repeat itself over and over, I recognized that sharing this was a cathartic event for them.”

The most helpful thing hospitalists can do for each other is listen without judgment.

“We need to realize it is going to happen to each and every one of us, and be prepared to offer a shoulder to cry on to help your colleague work through it,” says Dr. Feldman.

Dr. Wu believes clinicians need to examine their capacity to offer such support.

“We are not as reassuring as we could be,” Dr. Wu says. “I think we tend to hold back, maybe because we are so fearful of the whole idea. Really admitting that this is a normal, common event frightens us too much.”

What Hospitalist Groups Can Do

Cleo Hardin, MD, section chief of pediatric hospital medicine at the University of Arizona in Tucson, says her department deals with post-event distress several ways. Her doctors talk with her, share in their departmental morbidity and mortality conference, and don’t ignore errors and bad outcomes.

“Anytime there is a bad outcome,” Dr. Hardin says, “it is very important for the leader of the group to meet with the individual to ask, ‘What do we need to do to reduce the likelihood that you’re going to develop post-traumatic stress disorder and that you’re going to question everything you do in the future? You are a good doctor. How do we keep you being a good doctor?’ ”

A show of support by the whole team is of utmost importance.

“There is a tremendous amount of camaraderie in the group, and we all understand [that clinical practice] is not an exact science,” Dr. Hardin says. “There’s a lot of art in medicine.”

An expression of that art showed up several years ago in her hospital’s pediatrics unit when a child died on Christmas Day.

“On the day an event happens, I think the person is reeling and in shock and can’t hear anything,” Dr. Hardin says. “I called the hospitalist to ask whether he needed coverage. He declined, saying he was afraid if he got off the horse, he would never get back on.”

The following month they discussed the event at their mortality and morbidity conference; the entire hospitalist section was there.

“We sat together, and it was very clear to the hospitalist involved in the event that he was not there alone,” Dr. Hardin says. “We told him how much we appreciated him and respected him, and we were there to be his support.”

What Leaders Can Do

As the director of the hospitalist program at Johns Hopkins Hospital, Daniel J. Brotman, MD, FACP, understands that the level of upset after a bad outcome can be dramatic.

“Whether or not it was your fault, and independent of any medical-legal ramifications, although those certainly exist,” he says, “there’s a personal sense of just being a human being; of wanting to go back; questioning whether you made a right decision, a wrong decision; and facing whether you would change anything if you could do it again.”

Dr. Brotman believes in leading by example. “What you want is an open-door policy where faculty members can say, ‘Something bad happened, I need to get it off my chest, and I need to do it now,’” he says.

The group leader also needs to know what happened in case there’s a need for damage control beyond the hospitalist group. The leader should ultimately be the one who confers forgiveness.

“If somebody feels they are keeping a secret, it’s going to make matters worse,” Dr. Brotman says.

Research confirms the needs for “confession, restitution, and absolution,” and hospitalists need their competence validated.6

Even though I [have been] honest and said, ‘I don’t think I would have made that decision,’ I also have said, ‘I know that in terms of your thought process, you were acting in the best interest of the patient … and you’re one of the most compassionate physicians I know,” Dr. Brotman says.

As leaders gather information on an adverse event, they may also be in a better position to advocate for the hospitalist in subsequent conversations. In so doing, they can save that individual further embarrassment and humiliation.

“I hope that I’m able to process what I was experiencing in a way that doesn’t paralyze me,” Dr. Feldman says. “But I hope it informs me to the gravity of the situation.” TH

Andrea Sattinger is a medical writer based in North Carolina.

References

1. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078.
2. Goldberg RM, Kuhn G, Andrew LB, et al. Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002;39(3):287-292.
3. Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999;131(12):970-972.
4. Wu AW. Medical error: the second victim. BMJ. 2000;320(7237):726-727.
5. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265(16):2089-2094.
6. Wears RL, Wu AW. Dealing with failure: the aftermath of errors and adverse events. Ann Emerg Med. 2002;39(3):344-346.

Dr. Vincent A. Miller describes study results that suggest the addition of erlotinib to bevacizumab treatment for advanced non-small cell lung cancer extends progression-free survival compared with bevacizumab alone. Damian McNamara of the Global Medical News Network (GMNN) reports from the annual meeting of the American Society of Clinical Oncology in Orlando.

Dr. Vincent A. Miller describes study results that suggest the addition of erlotinib to bevacizumab treatment for advanced non-small cell lung cancer extends progression-free survival compared with bevacizumab alone. Damian McNamara of the Global Medical News Network (GMNN) reports from the annual meeting of the American Society of Clinical Oncology in Orlando.

Dr. Vincent A. Miller describes study results that suggest the addition of erlotinib to bevacizumab treatment for advanced non-small cell lung cancer extends progression-free survival compared with bevacizumab alone. Damian McNamara of the Global Medical News Network (GMNN) reports from the annual meeting of the American Society of Clinical Oncology in Orlando.

Dr. Rowan Chlebowski says his findings suggest an increased risk of non-small cell lung cancer associated with combination hormone therapy in a secondary analysis of data from the Women's Health Initiative study. Damian McNamara of the Global Medical News Network (GMNN) reports from the annual meeting of the American Society of Clinical Oncology in Orlando.

Dr. Rowan Chlebowski says his findings suggest an increased risk of non-small cell lung cancer associated with combination hormone therapy in a secondary analysis of data from the Women's Health Initiative study. Damian McNamara of the Global Medical News Network (GMNN) reports from the annual meeting of the American Society of Clinical Oncology in Orlando.

Dr. Rowan Chlebowski says his findings suggest an increased risk of non-small cell lung cancer associated with combination hormone therapy in a secondary analysis of data from the Women's Health Initiative study. Damian McNamara of the Global Medical News Network (GMNN) reports from the annual meeting of the American Society of Clinical Oncology in Orlando.

How healthy is your hospital? When considering your answer, tally up latex gloves, sterilizing cleansers, disposable instruments, and gowns as pluses. However, these items and hundreds more can count against your facility—when you consider the effect your hospital has on its immediate (and not so immediate) environment.

Hospitals are tremendous producers of toxins, including mercury and excess pharmaceuticals, as well as solid and hazardous wastes.

“In healthcare, the footprint we’re leaving behind directly impacts our health,” points out Mary Daubach-Larsen, director of material operations and chairman of the Green LEEDers Task Force at Advocate Lutheran General Hospital in Park Ridge, Ill.

Many hospitals are taking steps to reduce that footprint.

It’s Easy Being Green

Hospitals that want to make a commitment to become more environmentally friendly can hire a full-time expert to guide their efforts, and/or they can appoint a task force—often called a green team. Lutheran General has had great success with the green team model.

A 617-bed teaching, research, and tertiary care hospital and Level 1 trauma center, Lutheran General is one of the largest hospitals in the Chicago area. Under the leadership of Daubach-Larsen, the hospital’s Green LEEDers Task Force has made great strides in several areas, earning Lutheran General a national 2006 Partners in Change award from Hospitals for a Healthy Environment (H2E).

“We’ve been recycling for more than five years,” says Daubach-Larsen. “We’ve stepped up and widened our efforts to include recycling glass, plastic, and aluminum, and we’re also reducing mercury in our environment. We’re close to being mercury free—that’s a goal of all [U.S.] hospitals.”

Lutheran General is now focusing on reducing toxins, examining their cleansers and their disposal of pharmaceuticals.

Like most hospitals that make an environmental commitment, Lutheran General began its efforts with guidance from H2E (www.h2e-online.org), a nonprofit group founded by the American Hospital Association, the U.S. Environmental Protection Agency, Health Care Without Harm, and the American Nurses Association.

“H2E’s mission is to green the entire healthcare sector,” says Laura Brannen, executive director of H2E. “We focus on reducing waste, toxic chemicals, and mercury.” Hospitals can join H2E for free, and nearly 25% of all U.S. hospitals currently belong to H2E.

About the Green Team

An effective hospital green team should include members from multiple departments, to ensure that new environmentally friendly practices, such as using recycling bins for specific waste materials or purchasing “green” cleansers, are taught to all applicable staff and followed by all necessary departments.

“A traditional green team brings together people from a variety of backgrounds,” says Brannen. “It’s best to have a balance between people who need to be [on the team] and those who are motivated to be there because they care.”

In addition to Daubach-Larsen, Lutheran General’s task force includes four nurses, a physician, a psychologist, and representatives from food/nutrition, infection control, pharmacy, public relations, physician relations, and guests from facilities.

Catholic Healthcare West (CHW), which made a commitment to environmentally friendly practices in 1996, has an environmental action committee at each of its 40 hospitals.

“Each of these committees is responsible for establishing goals, monitoring progress, overseeing implementation, and training staff at their hospital,” explains Sister Mary Ellen Leciejewski, OP, ecology program coordinator, CHW, Santa Cruz, Calif. “They also look for groups in their community that they should be partnering with.”

In addition to this overall team, Brannen recommends two other groups for a successful approach: recycling coordinators and an executive group. “Recycling coordinators are department liaisons for the staff in that area,” she explains. “They’re responsible for number and placement of recycling bins, labeling, and staff training in their area. This brings implementation down directly where it’s happening. You can have a coordinator for every shift.”

As for the executive level, Brannen recommends an “environmental leadership council” made up of the highest-level executives possible from a variety of departments. “This council would only meet twice a year, or maybe quarterly,” explains Brannen. “They make institutional decisions and commitments. They might sign off on an environmental mission statement, for example. They legitimize in a big way what the institution is doing.”

Talk Trash

An easy and obvious place to start an environmental effort is by reducing the amount of waste your hospital produces.

“It makes sense to start with waste and move on from there,” advises Daubach-Larsen of starting a Green Team effort. “H2E offers a waste management template to help you gather data on your waste streams. You can use that data to show management” how much more efficiently your hospital can work. She advises that hospitals audit their various waste outputs, including hazardous waste, recycling, and general trash, with the help of their waste vendor. “You can save money immediately, starting with a study of what’s going on,” she says.

With the data collected on waste and the buy-in of management, you can begin the work of shifting more waste toward recycling—or perhaps eliminating some waste altogether.

“Improve your relationship with your waste vendor,” advises Daubach-Larsen. “You can start to push them to accept more recyclables. When they realize there’s a demand, they’ll accept different materials.”

Address Toxins, Energy, and More

Beyond reducing waste, hospitals can make many environmental improvements—it’s simply a matter of choosing priorities. “The spectrum is large and can be overwhelming,” admits Daubach-Larsen.

In addition to waste and recycling, H2E helps hospitals address a wide variety of environmental issues. “We’ve moved on to environmentally friendly purchasing, green building, safer material choices, and energy efficiency,” says Brannen.

One area many green hospitals are beginning to watch closely is their purchasing, including their vendors. “We’re members of a group purchasing company that has green management strategies,” says Daubach-Larsen. “Most of the big groups are now on that bandwagon.” As part of their green purchasing habits, Lutheran General is trying to expand their use of products that are environmentally friendly. “We’ve also started sending out an RFP [request for proposal] asking vendors about their practices,” says Daubach-Larsen.

“Supply chain management is so important,” stresses Leciejewski. “If we watch what’s coming in our front door, we don’t have to worry so much about what we’re sending out our back door.”

CHW is currently working on multiple projects, including reprocessing surgical instruments, responsible disposal of their electronic waste (such as computers), reusable sharp’s containers, and a commitment to the healthiest food possible. “We’re looking at everything from working with organic vendors to the silverware and Styrofoam we use in our cafeterias,” says Leciejewski.

Another area of environmental consciousness is new construction. So-called green building is becoming a trend that reaches beyond healthcare. “If you’re not designing a green building before you break ground, you’re behind the times,” says Brannen. “This movement is really gaining steam, and the cost payback is pretty staggering over the life of the building.”

Daubach-Larsen adds, “Even if you’re not building, you can still incorporate new behaviors that will reduce your footprint on the environment.”

Save the Environment=Save Money

Are green practices too expensive for some hospitals? “The challenge is that people say they don’t have the money to spend [on better environmental practices], but they’re spending too much [now] and they’re tossing resources,” says Brannen.

Daubach-Larsen adds, “There are a lot of efficiencies” that can be realized through green practices. “Reducing solid waste and increasing recycling can save money,” she points out. “Our numbers of hazardous waste, or ‘red bag waste,’ are very low compared to other hospitals—it costs more to dispose of this waste.”

Green Hospitalists?

Where do hospitalists and other physicians fit into the green team picture? “There are hospitalists [who] get the relationships between their hospital[s] and the environment,” says Daubach-Larsen. “They can be ambassadors for that message.”

While green team leadership tends to fall on hospital operations staff, physicians can provide tremendous support simply by advocating with hospital leadership. “Executive sponsorship is key,” says Daubach-Larsen. “And physicians have a direct line to management. They can communicate that their satisfaction in the organization would be improved if that organization took an interest in the environment.”

Brannen says that physicians are “often the hardest community to reach” when spreading the message of environmentally friendly changes. “They can advocate or they can pitch in; having them in a leadership role is best, particularly if they have clout.”

Leciejewski recommends that hospitalists get involved in specific efforts. “We know that PVC (polyvinyl chloride )/DEHP (di[2-ethylhexyl]phthalate) IV bags are a known carcinogen, especially for preemies,” she says. “Doctors can support changing to different products or bring new products to our attention. They can write letters to [the companies we purchase from].”

Has your hospital made a commitment to reduce waste or otherwise reduce its footprint on the environment? If not, consider recommending a green team to start with some easy changes that can make a difference—and join the growing number of hospitals and healthcare workers committed to healing the environment.

“By collaborating, we can make a difference,” says Leciejewski. “Restoring the earth depends on us coming together as a community.” TH

Jane Jerrard is a frequent contributor to The Hospitalist.

How healthy is your hospital? When considering your answer, tally up latex gloves, sterilizing cleansers, disposable instruments, and gowns as pluses. However, these items and hundreds more can count against your facility—when you consider the effect your hospital has on its immediate (and not so immediate) environment.

Hospitals are tremendous producers of toxins, including mercury and excess pharmaceuticals, as well as solid and hazardous wastes.

“In healthcare, the footprint we’re leaving behind directly impacts our health,” points out Mary Daubach-Larsen, director of material operations and chairman of the Green LEEDers Task Force at Advocate Lutheran General Hospital in Park Ridge, Ill.

Many hospitals are taking steps to reduce that footprint.

It’s Easy Being Green

Hospitals that want to make a commitment to become more environmentally friendly can hire a full-time expert to guide their efforts, and/or they can appoint a task force—often called a green team. Lutheran General has had great success with the green team model.

A 617-bed teaching, research, and tertiary care hospital and Level 1 trauma center, Lutheran General is one of the largest hospitals in the Chicago area. Under the leadership of Daubach-Larsen, the hospital’s Green LEEDers Task Force has made great strides in several areas, earning Lutheran General a national 2006 Partners in Change award from Hospitals for a Healthy Environment (H2E).

“We’ve been recycling for more than five years,” says Daubach-Larsen. “We’ve stepped up and widened our efforts to include recycling glass, plastic, and aluminum, and we’re also reducing mercury in our environment. We’re close to being mercury free—that’s a goal of all [U.S.] hospitals.”

Lutheran General is now focusing on reducing toxins, examining their cleansers and their disposal of pharmaceuticals.

Like most hospitals that make an environmental commitment, Lutheran General began its efforts with guidance from H2E (www.h2e-online.org), a nonprofit group founded by the American Hospital Association, the U.S. Environmental Protection Agency, Health Care Without Harm, and the American Nurses Association.

“H2E’s mission is to green the entire healthcare sector,” says Laura Brannen, executive director of H2E. “We focus on reducing waste, toxic chemicals, and mercury.” Hospitals can join H2E for free, and nearly 25% of all U.S. hospitals currently belong to H2E.

About the Green Team

An effective hospital green team should include members from multiple departments, to ensure that new environmentally friendly practices, such as using recycling bins for specific waste materials or purchasing “green” cleansers, are taught to all applicable staff and followed by all necessary departments.

“A traditional green team brings together people from a variety of backgrounds,” says Brannen. “It’s best to have a balance between people who need to be [on the team] and those who are motivated to be there because they care.”

In addition to Daubach-Larsen, Lutheran General’s task force includes four nurses, a physician, a psychologist, and representatives from food/nutrition, infection control, pharmacy, public relations, physician relations, and guests from facilities.

Catholic Healthcare West (CHW), which made a commitment to environmentally friendly practices in 1996, has an environmental action committee at each of its 40 hospitals.

“Each of these committees is responsible for establishing goals, monitoring progress, overseeing implementation, and training staff at their hospital,” explains Sister Mary Ellen Leciejewski, OP, ecology program coordinator, CHW, Santa Cruz, Calif. “They also look for groups in their community that they should be partnering with.”

In addition to this overall team, Brannen recommends two other groups for a successful approach: recycling coordinators and an executive group. “Recycling coordinators are department liaisons for the staff in that area,” she explains. “They’re responsible for number and placement of recycling bins, labeling, and staff training in their area. This brings implementation down directly where it’s happening. You can have a coordinator for every shift.”

As for the executive level, Brannen recommends an “environmental leadership council” made up of the highest-level executives possible from a variety of departments. “This council would only meet twice a year, or maybe quarterly,” explains Brannen. “They make institutional decisions and commitments. They might sign off on an environmental mission statement, for example. They legitimize in a big way what the institution is doing.”

Talk Trash

An easy and obvious place to start an environmental effort is by reducing the amount of waste your hospital produces.

“It makes sense to start with waste and move on from there,” advises Daubach-Larsen of starting a Green Team effort. “H2E offers a waste management template to help you gather data on your waste streams. You can use that data to show management” how much more efficiently your hospital can work. She advises that hospitals audit their various waste outputs, including hazardous waste, recycling, and general trash, with the help of their waste vendor. “You can save money immediately, starting with a study of what’s going on,” she says.

With the data collected on waste and the buy-in of management, you can begin the work of shifting more waste toward recycling—or perhaps eliminating some waste altogether.

“Improve your relationship with your waste vendor,” advises Daubach-Larsen. “You can start to push them to accept more recyclables. When they realize there’s a demand, they’ll accept different materials.”

Address Toxins, Energy, and More

Beyond reducing waste, hospitals can make many environmental improvements—it’s simply a matter of choosing priorities. “The spectrum is large and can be overwhelming,” admits Daubach-Larsen.

In addition to waste and recycling, H2E helps hospitals address a wide variety of environmental issues. “We’ve moved on to environmentally friendly purchasing, green building, safer material choices, and energy efficiency,” says Brannen.

One area many green hospitals are beginning to watch closely is their purchasing, including their vendors. “We’re members of a group purchasing company that has green management strategies,” says Daubach-Larsen. “Most of the big groups are now on that bandwagon.” As part of their green purchasing habits, Lutheran General is trying to expand their use of products that are environmentally friendly. “We’ve also started sending out an RFP [request for proposal] asking vendors about their practices,” says Daubach-Larsen.

“Supply chain management is so important,” stresses Leciejewski. “If we watch what’s coming in our front door, we don’t have to worry so much about what we’re sending out our back door.”

CHW is currently working on multiple projects, including reprocessing surgical instruments, responsible disposal of their electronic waste (such as computers), reusable sharp’s containers, and a commitment to the healthiest food possible. “We’re looking at everything from working with organic vendors to the silverware and Styrofoam we use in our cafeterias,” says Leciejewski.

Another area of environmental consciousness is new construction. So-called green building is becoming a trend that reaches beyond healthcare. “If you’re not designing a green building before you break ground, you’re behind the times,” says Brannen. “This movement is really gaining steam, and the cost payback is pretty staggering over the life of the building.”

Daubach-Larsen adds, “Even if you’re not building, you can still incorporate new behaviors that will reduce your footprint on the environment.”

Save the Environment=Save Money

Are green practices too expensive for some hospitals? “The challenge is that people say they don’t have the money to spend [on better environmental practices], but they’re spending too much [now] and they’re tossing resources,” says Brannen.

Daubach-Larsen adds, “There are a lot of efficiencies” that can be realized through green practices. “Reducing solid waste and increasing recycling can save money,” she points out. “Our numbers of hazardous waste, or ‘red bag waste,’ are very low compared to other hospitals—it costs more to dispose of this waste.”

Green Hospitalists?

Where do hospitalists and other physicians fit into the green team picture? “There are hospitalists [who] get the relationships between their hospital[s] and the environment,” says Daubach-Larsen. “They can be ambassadors for that message.”

While green team leadership tends to fall on hospital operations staff, physicians can provide tremendous support simply by advocating with hospital leadership. “Executive sponsorship is key,” says Daubach-Larsen. “And physicians have a direct line to management. They can communicate that their satisfaction in the organization would be improved if that organization took an interest in the environment.”

Brannen says that physicians are “often the hardest community to reach” when spreading the message of environmentally friendly changes. “They can advocate or they can pitch in; having them in a leadership role is best, particularly if they have clout.”

Leciejewski recommends that hospitalists get involved in specific efforts. “We know that PVC (polyvinyl chloride )/DEHP (di[2-ethylhexyl]phthalate) IV bags are a known carcinogen, especially for preemies,” she says. “Doctors can support changing to different products or bring new products to our attention. They can write letters to [the companies we purchase from].”

Has your hospital made a commitment to reduce waste or otherwise reduce its footprint on the environment? If not, consider recommending a green team to start with some easy changes that can make a difference—and join the growing number of hospitals and healthcare workers committed to healing the environment.

“By collaborating, we can make a difference,” says Leciejewski. “Restoring the earth depends on us coming together as a community.” TH

Jane Jerrard is a frequent contributor to The Hospitalist.

How healthy is your hospital? When considering your answer, tally up latex gloves, sterilizing cleansers, disposable instruments, and gowns as pluses. However, these items and hundreds more can count against your facility—when you consider the effect your hospital has on its immediate (and not so immediate) environment.

Hospitals are tremendous producers of toxins, including mercury and excess pharmaceuticals, as well as solid and hazardous wastes.

“In healthcare, the footprint we’re leaving behind directly impacts our health,” points out Mary Daubach-Larsen, director of material operations and chairman of the Green LEEDers Task Force at Advocate Lutheran General Hospital in Park Ridge, Ill.

Many hospitals are taking steps to reduce that footprint.

It’s Easy Being Green

Hospitals that want to make a commitment to become more environmentally friendly can hire a full-time expert to guide their efforts, and/or they can appoint a task force—often called a green team. Lutheran General has had great success with the green team model.

A 617-bed teaching, research, and tertiary care hospital and Level 1 trauma center, Lutheran General is one of the largest hospitals in the Chicago area. Under the leadership of Daubach-Larsen, the hospital’s Green LEEDers Task Force has made great strides in several areas, earning Lutheran General a national 2006 Partners in Change award from Hospitals for a Healthy Environment (H2E).

“We’ve been recycling for more than five years,” says Daubach-Larsen. “We’ve stepped up and widened our efforts to include recycling glass, plastic, and aluminum, and we’re also reducing mercury in our environment. We’re close to being mercury free—that’s a goal of all [U.S.] hospitals.”

Lutheran General is now focusing on reducing toxins, examining their cleansers and their disposal of pharmaceuticals.

Like most hospitals that make an environmental commitment, Lutheran General began its efforts with guidance from H2E (www.h2e-online.org), a nonprofit group founded by the American Hospital Association, the U.S. Environmental Protection Agency, Health Care Without Harm, and the American Nurses Association.

“H2E’s mission is to green the entire healthcare sector,” says Laura Brannen, executive director of H2E. “We focus on reducing waste, toxic chemicals, and mercury.” Hospitals can join H2E for free, and nearly 25% of all U.S. hospitals currently belong to H2E.

About the Green Team

An effective hospital green team should include members from multiple departments, to ensure that new environmentally friendly practices, such as using recycling bins for specific waste materials or purchasing “green” cleansers, are taught to all applicable staff and followed by all necessary departments.

“A traditional green team brings together people from a variety of backgrounds,” says Brannen. “It’s best to have a balance between people who need to be [on the team] and those who are motivated to be there because they care.”

In addition to Daubach-Larsen, Lutheran General’s task force includes four nurses, a physician, a psychologist, and representatives from food/nutrition, infection control, pharmacy, public relations, physician relations, and guests from facilities.

Catholic Healthcare West (CHW), which made a commitment to environmentally friendly practices in 1996, has an environmental action committee at each of its 40 hospitals.

“Each of these committees is responsible for establishing goals, monitoring progress, overseeing implementation, and training staff at their hospital,” explains Sister Mary Ellen Leciejewski, OP, ecology program coordinator, CHW, Santa Cruz, Calif. “They also look for groups in their community that they should be partnering with.”

In addition to this overall team, Brannen recommends two other groups for a successful approach: recycling coordinators and an executive group. “Recycling coordinators are department liaisons for the staff in that area,” she explains. “They’re responsible for number and placement of recycling bins, labeling, and staff training in their area. This brings implementation down directly where it’s happening. You can have a coordinator for every shift.”

As for the executive level, Brannen recommends an “environmental leadership council” made up of the highest-level executives possible from a variety of departments. “This council would only meet twice a year, or maybe quarterly,” explains Brannen. “They make institutional decisions and commitments. They might sign off on an environmental mission statement, for example. They legitimize in a big way what the institution is doing.”

Talk Trash

An easy and obvious place to start an environmental effort is by reducing the amount of waste your hospital produces.

“It makes sense to start with waste and move on from there,” advises Daubach-Larsen of starting a Green Team effort. “H2E offers a waste management template to help you gather data on your waste streams. You can use that data to show management” how much more efficiently your hospital can work. She advises that hospitals audit their various waste outputs, including hazardous waste, recycling, and general trash, with the help of their waste vendor. “You can save money immediately, starting with a study of what’s going on,” she says.

With the data collected on waste and the buy-in of management, you can begin the work of shifting more waste toward recycling—or perhaps eliminating some waste altogether.

“Improve your relationship with your waste vendor,” advises Daubach-Larsen. “You can start to push them to accept more recyclables. When they realize there’s a demand, they’ll accept different materials.”

Address Toxins, Energy, and More

Beyond reducing waste, hospitals can make many environmental improvements—it’s simply a matter of choosing priorities. “The spectrum is large and can be overwhelming,” admits Daubach-Larsen.

In addition to waste and recycling, H2E helps hospitals address a wide variety of environmental issues. “We’ve moved on to environmentally friendly purchasing, green building, safer material choices, and energy efficiency,” says Brannen.

One area many green hospitals are beginning to watch closely is their purchasing, including their vendors. “We’re members of a group purchasing company that has green management strategies,” says Daubach-Larsen. “Most of the big groups are now on that bandwagon.” As part of their green purchasing habits, Lutheran General is trying to expand their use of products that are environmentally friendly. “We’ve also started sending out an RFP [request for proposal] asking vendors about their practices,” says Daubach-Larsen.

“Supply chain management is so important,” stresses Leciejewski. “If we watch what’s coming in our front door, we don’t have to worry so much about what we’re sending out our back door.”

CHW is currently working on multiple projects, including reprocessing surgical instruments, responsible disposal of their electronic waste (such as computers), reusable sharp’s containers, and a commitment to the healthiest food possible. “We’re looking at everything from working with organic vendors to the silverware and Styrofoam we use in our cafeterias,” says Leciejewski.

Another area of environmental consciousness is new construction. So-called green building is becoming a trend that reaches beyond healthcare. “If you’re not designing a green building before you break ground, you’re behind the times,” says Brannen. “This movement is really gaining steam, and the cost payback is pretty staggering over the life of the building.”

Daubach-Larsen adds, “Even if you’re not building, you can still incorporate new behaviors that will reduce your footprint on the environment.”

Save the Environment=Save Money

Are green practices too expensive for some hospitals? “The challenge is that people say they don’t have the money to spend [on better environmental practices], but they’re spending too much [now] and they’re tossing resources,” says Brannen.

Daubach-Larsen adds, “There are a lot of efficiencies” that can be realized through green practices. “Reducing solid waste and increasing recycling can save money,” she points out. “Our numbers of hazardous waste, or ‘red bag waste,’ are very low compared to other hospitals—it costs more to dispose of this waste.”

Green Hospitalists?

Where do hospitalists and other physicians fit into the green team picture? “There are hospitalists [who] get the relationships between their hospital[s] and the environment,” says Daubach-Larsen. “They can be ambassadors for that message.”

While green team leadership tends to fall on hospital operations staff, physicians can provide tremendous support simply by advocating with hospital leadership. “Executive sponsorship is key,” says Daubach-Larsen. “And physicians have a direct line to management. They can communicate that their satisfaction in the organization would be improved if that organization took an interest in the environment.”

Brannen says that physicians are “often the hardest community to reach” when spreading the message of environmentally friendly changes. “They can advocate or they can pitch in; having them in a leadership role is best, particularly if they have clout.”

Leciejewski recommends that hospitalists get involved in specific efforts. “We know that PVC (polyvinyl chloride )/DEHP (di[2-ethylhexyl]phthalate) IV bags are a known carcinogen, especially for preemies,” she says. “Doctors can support changing to different products or bring new products to our attention. They can write letters to [the companies we purchase from].”

Has your hospital made a commitment to reduce waste or otherwise reduce its footprint on the environment? If not, consider recommending a green team to start with some easy changes that can make a difference—and join the growing number of hospitals and healthcare workers committed to healing the environment.

“By collaborating, we can make a difference,” says Leciejewski. “Restoring the earth depends on us coming together as a community.” TH

Jane Jerrard is a frequent contributor to The Hospitalist.

Resident Restrictions Might Be HM Game-Changer

I have heard regulators are thinking about further restricting resident work hours. Is this true? Do you think this has helped or hindered patient care? Is there any discussion about restriction of hospitalist work hours? I am working harder than I ever did during training. Have these rules affected the hospitalist field?

H. Jackson, MD, Dover, Del.

Dr. Hospitalist responds:

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established rules to limit the resident work schedule. The rules included an 80-hour limit on resident workweeks. Training programs around the country experienced difficulties in complying with the rules. Many hospitals established or expanded existing hospitalist programs to help their training programs comply with the rule change, which meant more jobs for hospitalists. From this perspective, the rules were a boon for hospitalists. But the rules also had some unintended consequences. Shorter resident shifts meant more handoffs, and this resulted in an increase in medical errors. Not only do we not do a good job of teaching patient handoffs to our trainees, but most attending physicians also do an inadequate job of communicating patient handoffs.

As you noted, a new report (www.nationalacademies.org/morenews/20081202.html) from the Institute of Medicine (IOM) called for changes to the ACGME rules. The IOM report does not call for a reduction in the 80-hour workweek, but it does recommend several changes to ACGME rules. The IOM calls for residents to work no more than 16 consecutive hours without sleep. It also calls for changes to the present ACGME rules regarding resident time off. Residents should:

• Have 12 hours off after every night shift, 10 hours off after every day shift, and 14 hours off after any shift of 30 hours;
• Not be on call in the hospital more frequently than every third night, with no averaging; and
• Have at least one day off per week, with no averaging.

The IOM report also calls for increased on-site supervision of residents, including immediate access to a supervisory physician for interns. For now, the IOM report is just that—a report. We’ll have to wait and see how ACGME reacts to these recommendations.

What is the potential impact for hospitalists? The work-schedule recommendations could mean residents will work fewer consecutive hours in the hospital. This has the potential to increase the demand for hospitalists to see patients, not only on the medical service, but on other clinical services as well. For example, we may see more hospitalists working with surgeons to manage surgical inpatients. Hospitalist programs will have to figure out a way to work with surgeons without feeling as though the surgeons are “dropping off” patients after surgeries.

With the current shortage of hospitalists, institutions and HM programs could hire more nonphysician clinical providers, such as nurse practitioners and physician assistants. Many hospitalist programs have struggled to incorporate these providers into their workflow in an efficient and cost-effective fashion. Such problems represent opportunities for HM.

The further fragmentation of the resident schedule could create additional patient handoffs. Early in the HM movement, the “voltage drop” issue was a hot topic. Since then, HM has not done enough to standardize the handoff and teach it to others. I encourage all HM programs to resolve the issue of patient handoffs. This is imperative to the safety of our patients.

Use Metrics to Identify Documentation and Coding Errors

I am the leader of a hospitalist group. We have a number of recent graduates in our group, and I have a feeling that not everyone is billing correctly. Do you have any suggestions on how I remedy this problem?

D. Perman, MD, Augusta, Ga.

Dr. Hospitalist responds:

I would not be surprised if your suspicions are correct. Unfortunately, many young physicians do not have a firm grasp on the rules and regulations surrounding coding and documentation. But before you set out to find a remedy, you need to identify and understand the problem.

I suggest you start by collecting data. This is most easily done by involving your administrative staff and billing service. Create individual and group dashboards to help you and the individual physicians examine the data. The first step is to determine whether the doctors in your group are submitting a bill with each clinical encounter. Measure the number of days between the date of service and the date they submit the bill. Create metrics and put them on the dashboard. For example, one could measure bills submitted divided by clinical encounters; another would calculate the percent of bills submitted within 72 hours of the service date.

Next, look at the individual and group code distributions. Assuming that all members of your group have a similar job description and see the same groups of patients, the code distribution should be similar. For example, the percentage of Level 3, Level 2, and Level 1 initial admission codes should be similar among all members of your group. A disparity would suggest that one or more physicians is not documenting and coding correctly.

Use your dashboard to compare individual and group distribution. In my group, I provide each physician with the metrics on their personal distribution of codes for the fiscal year, along with their distribution of codes from previous years. When I do this, I also provide each physician with our group’s distribution of codes for the present and previous years. This allows individual physicians to compare historical trends for themselves and the entire group. I do not share individual data with other individuals in the group.

Lastly, provide the distribution of codes for internal-medicine physicians from Medicare. This information is available at www.cms.hhs.gov/pqri/. It is important to note that I am not holding up the Medicare data or our group data as the standard; it is merely a reflection of how other internists in our group and across the country are billing.

This data is intended to supplement, not replace, our annual training on documentation, coding, and compliance. I have found that pushing this data to our physicians has helped them understand the importance of creating a system to ensure that all bills are submitted and coded appropriately to the level of service and documentation. TH

Resident Restrictions Might Be HM Game-Changer

I have heard regulators are thinking about further restricting resident work hours. Is this true? Do you think this has helped or hindered patient care? Is there any discussion about restriction of hospitalist work hours? I am working harder than I ever did during training. Have these rules affected the hospitalist field?

H. Jackson, MD, Dover, Del.

Dr. Hospitalist responds:

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established rules to limit the resident work schedule. The rules included an 80-hour limit on resident workweeks. Training programs around the country experienced difficulties in complying with the rules. Many hospitals established or expanded existing hospitalist programs to help their training programs comply with the rule change, which meant more jobs for hospitalists. From this perspective, the rules were a boon for hospitalists. But the rules also had some unintended consequences. Shorter resident shifts meant more handoffs, and this resulted in an increase in medical errors. Not only do we not do a good job of teaching patient handoffs to our trainees, but most attending physicians also do an inadequate job of communicating patient handoffs.

As you noted, a new report (www.nationalacademies.org/morenews/20081202.html) from the Institute of Medicine (IOM) called for changes to the ACGME rules. The IOM report does not call for a reduction in the 80-hour workweek, but it does recommend several changes to ACGME rules. The IOM calls for residents to work no more than 16 consecutive hours without sleep. It also calls for changes to the present ACGME rules regarding resident time off. Residents should:

• Have 12 hours off after every night shift, 10 hours off after every day shift, and 14 hours off after any shift of 30 hours;
• Not be on call in the hospital more frequently than every third night, with no averaging; and
• Have at least one day off per week, with no averaging.

The IOM report also calls for increased on-site supervision of residents, including immediate access to a supervisory physician for interns. For now, the IOM report is just that—a report. We’ll have to wait and see how ACGME reacts to these recommendations.

What is the potential impact for hospitalists? The work-schedule recommendations could mean residents will work fewer consecutive hours in the hospital. This has the potential to increase the demand for hospitalists to see patients, not only on the medical service, but on other clinical services as well. For example, we may see more hospitalists working with surgeons to manage surgical inpatients. Hospitalist programs will have to figure out a way to work with surgeons without feeling as though the surgeons are “dropping off” patients after surgeries.

With the current shortage of hospitalists, institutions and HM programs could hire more nonphysician clinical providers, such as nurse practitioners and physician assistants. Many hospitalist programs have struggled to incorporate these providers into their workflow in an efficient and cost-effective fashion. Such problems represent opportunities for HM.

The further fragmentation of the resident schedule could create additional patient handoffs. Early in the HM movement, the “voltage drop” issue was a hot topic. Since then, HM has not done enough to standardize the handoff and teach it to others. I encourage all HM programs to resolve the issue of patient handoffs. This is imperative to the safety of our patients.

Use Metrics to Identify Documentation and Coding Errors

I am the leader of a hospitalist group. We have a number of recent graduates in our group, and I have a feeling that not everyone is billing correctly. Do you have any suggestions on how I remedy this problem?

D. Perman, MD, Augusta, Ga.

Dr. Hospitalist responds:

I would not be surprised if your suspicions are correct. Unfortunately, many young physicians do not have a firm grasp on the rules and regulations surrounding coding and documentation. But before you set out to find a remedy, you need to identify and understand the problem.

I suggest you start by collecting data. This is most easily done by involving your administrative staff and billing service. Create individual and group dashboards to help you and the individual physicians examine the data. The first step is to determine whether the doctors in your group are submitting a bill with each clinical encounter. Measure the number of days between the date of service and the date they submit the bill. Create metrics and put them on the dashboard. For example, one could measure bills submitted divided by clinical encounters; another would calculate the percent of bills submitted within 72 hours of the service date.

Next, look at the individual and group code distributions. Assuming that all members of your group have a similar job description and see the same groups of patients, the code distribution should be similar. For example, the percentage of Level 3, Level 2, and Level 1 initial admission codes should be similar among all members of your group. A disparity would suggest that one or more physicians is not documenting and coding correctly.

Use your dashboard to compare individual and group distribution. In my group, I provide each physician with the metrics on their personal distribution of codes for the fiscal year, along with their distribution of codes from previous years. When I do this, I also provide each physician with our group’s distribution of codes for the present and previous years. This allows individual physicians to compare historical trends for themselves and the entire group. I do not share individual data with other individuals in the group.

Lastly, provide the distribution of codes for internal-medicine physicians from Medicare. This information is available at www.cms.hhs.gov/pqri/. It is important to note that I am not holding up the Medicare data or our group data as the standard; it is merely a reflection of how other internists in our group and across the country are billing.

This data is intended to supplement, not replace, our annual training on documentation, coding, and compliance. I have found that pushing this data to our physicians has helped them understand the importance of creating a system to ensure that all bills are submitted and coded appropriately to the level of service and documentation. TH

Resident Restrictions Might Be HM Game-Changer

I have heard regulators are thinking about further restricting resident work hours. Is this true? Do you think this has helped or hindered patient care? Is there any discussion about restriction of hospitalist work hours? I am working harder than I ever did during training. Have these rules affected the hospitalist field?

H. Jackson, MD, Dover, Del.

Dr. Hospitalist responds:

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established rules to limit the resident work schedule. The rules included an 80-hour limit on resident workweeks. Training programs around the country experienced difficulties in complying with the rules. Many hospitals established or expanded existing hospitalist programs to help their training programs comply with the rule change, which meant more jobs for hospitalists. From this perspective, the rules were a boon for hospitalists. But the rules also had some unintended consequences. Shorter resident shifts meant more handoffs, and this resulted in an increase in medical errors. Not only do we not do a good job of teaching patient handoffs to our trainees, but most attending physicians also do an inadequate job of communicating patient handoffs.

As you noted, a new report (www.nationalacademies.org/morenews/20081202.html) from the Institute of Medicine (IOM) called for changes to the ACGME rules. The IOM report does not call for a reduction in the 80-hour workweek, but it does recommend several changes to ACGME rules. The IOM calls for residents to work no more than 16 consecutive hours without sleep. It also calls for changes to the present ACGME rules regarding resident time off. Residents should:

• Have 12 hours off after every night shift, 10 hours off after every day shift, and 14 hours off after any shift of 30 hours;
• Not be on call in the hospital more frequently than every third night, with no averaging; and
• Have at least one day off per week, with no averaging.

The IOM report also calls for increased on-site supervision of residents, including immediate access to a supervisory physician for interns. For now, the IOM report is just that—a report. We’ll have to wait and see how ACGME reacts to these recommendations.

What is the potential impact for hospitalists? The work-schedule recommendations could mean residents will work fewer consecutive hours in the hospital. This has the potential to increase the demand for hospitalists to see patients, not only on the medical service, but on other clinical services as well. For example, we may see more hospitalists working with surgeons to manage surgical inpatients. Hospitalist programs will have to figure out a way to work with surgeons without feeling as though the surgeons are “dropping off” patients after surgeries.

With the current shortage of hospitalists, institutions and HM programs could hire more nonphysician clinical providers, such as nurse practitioners and physician assistants. Many hospitalist programs have struggled to incorporate these providers into their workflow in an efficient and cost-effective fashion. Such problems represent opportunities for HM.

The further fragmentation of the resident schedule could create additional patient handoffs. Early in the HM movement, the “voltage drop” issue was a hot topic. Since then, HM has not done enough to standardize the handoff and teach it to others. I encourage all HM programs to resolve the issue of patient handoffs. This is imperative to the safety of our patients.

Use Metrics to Identify Documentation and Coding Errors

I am the leader of a hospitalist group. We have a number of recent graduates in our group, and I have a feeling that not everyone is billing correctly. Do you have any suggestions on how I remedy this problem?

D. Perman, MD, Augusta, Ga.

Dr. Hospitalist responds:

I would not be surprised if your suspicions are correct. Unfortunately, many young physicians do not have a firm grasp on the rules and regulations surrounding coding and documentation. But before you set out to find a remedy, you need to identify and understand the problem.

I suggest you start by collecting data. This is most easily done by involving your administrative staff and billing service. Create individual and group dashboards to help you and the individual physicians examine the data. The first step is to determine whether the doctors in your group are submitting a bill with each clinical encounter. Measure the number of days between the date of service and the date they submit the bill. Create metrics and put them on the dashboard. For example, one could measure bills submitted divided by clinical encounters; another would calculate the percent of bills submitted within 72 hours of the service date.

Next, look at the individual and group code distributions. Assuming that all members of your group have a similar job description and see the same groups of patients, the code distribution should be similar. For example, the percentage of Level 3, Level 2, and Level 1 initial admission codes should be similar among all members of your group. A disparity would suggest that one or more physicians is not documenting and coding correctly.

Use your dashboard to compare individual and group distribution. In my group, I provide each physician with the metrics on their personal distribution of codes for the fiscal year, along with their distribution of codes from previous years. When I do this, I also provide each physician with our group’s distribution of codes for the present and previous years. This allows individual physicians to compare historical trends for themselves and the entire group. I do not share individual data with other individuals in the group.

Lastly, provide the distribution of codes for internal-medicine physicians from Medicare. This information is available at www.cms.hhs.gov/pqri/. It is important to note that I am not holding up the Medicare data or our group data as the standard; it is merely a reflection of how other internists in our group and across the country are billing.

This data is intended to supplement, not replace, our annual training on documentation, coding, and compliance. I have found that pushing this data to our physicians has helped them understand the importance of creating a system to ensure that all bills are submitted and coded appropriately to the level of service and documentation. TH

Editor’s note: This is the second of a two-part series addressing issues at large HM groups.

Last month (“The Bigger They Are…,” May 2009, p. 58), I discussed the difficulty large HM groups (more than 20 full-time equivalent hospitalists) face in trying to ensure that nurses and other staff always know which hospitalist is attending a patient daily, as well as issues raised by the common practice of separating admitter and rounder shifts. This month, I want to address patient distribution and economic issues faced by large groups.

Patient Census

Large and small groups often work diligently to ensure all rounding doctors start the day with a nearly identical patient load. Such “load leveling” might take only a few minutes in groups of two or three rounding doctors, but it may take up to an hour a day if there are eight to 10 rounding doctors. Think about what this costs a large group. If a group has eight rounders spending the first 30 minutes of each day distributing patients, the practice is devoting 1,460 hours annually to this function. Those 1,460 hours equate to 0.7 FTE, and if each FTE costs the practice $220,000 annually in salary and benefits, then the practice is spending $154,000 per year to distribute patients each morning.

Is that the best way to use $154,000?

An alternative is to establish a system that allows the evening and night admitters to know in advance which rounding doctor will assume each patient’s care the next morning. The night/evening admitters would then write “admit to Dr. Satriani” for the first new admission, and “admit to Dr. Johnson” for the second, and so on. The hospital would never list evening/night admitters as a patient’s attending on the chart or in the computer. And each rounding doctor could arrive in the morning to find a list of new patients from overnight, eliminating the need for a meeting of all rounding doctors just to distribute the patients. There may be other reasons to meet each morning, such as case management rounds, but eliminating the need to spend time distributing patients will make the meetings shorter and get everyone out to the floors to see patients more quickly.

There are two simple ways the evening/night admitters can know how to assign new patients to the rounding doctors for the next morning. If the group wants to have each rounding doctor start with a nearly identical patient load, then the rounding doctors could indicate their load at the end of each day and the evening/night admitters would follow an algorithm of assigning the first admissions to the doctor who finished the prior day with a lighter load. The other option is for evening/night admitters to assign new patients through the night according to a fixed protocol, which wouldn’t vary based on the current patient load of each rounder. Of course, this will mean daily patient load could vary significantly from one rounder to the next, but over any long period, the workloads will tend to even out.

Elusive Economy of Scale

Hospitalists and hospital executives tend to have a different view of the benefits of practice growth to require more hospitalist FTEs. The hospitalists themselves often are convinced that when the group has more doctors, there will be more scheduling flexibility for each individual doctor, and perhaps each doctor will have to work fewer weekends. Sadly, neither is true to any significant degree in most practices. Some aspects of scheduling are easier when there are more doctors. For example, it usually is easier to find someone to fill in for an unexpected absence in larger groups. However, each doctor’s schedule usually doesn’t get much better or more flexible.

Hospital executives, or whoever is responsible for coming up with funding to support the practice, often look at a larger practice as one that can take advantage of economies of scale. For example, executives may project that when the practice is larger, the hospital’s contribution to the practice on a per-FTE or per-encounter basis will become smaller. But just like the elusive scheduling benefit of larger groups, few practices realize any economies of scale. The vast majority of the costs in most programs are provider labor costs, which scale with program volume. So in most cases, the larger a practice becomes, the larger the overall hospital financial support will be on a roughly linear basis.

More often than not, night-shift work does become more cost-effective as practices grow. For example, an in-house night shift for a practice of eight FTEs might generate $200 to $400 in collected professional fee revenue each night, leaving the hospital to pay the remaining $700 to $900 each night. (These numbers are for illustration and aren’t intended to represent benchmarks or realistic targets for any practice.) But as the practice grows to support 20 FTE hospitalists in total, nights get busier. The night doctor might average three or four admissions per night in an eight-FTE practice but could average 10 or more in a 20-FTE practice. Those 10 admissions might generate around $1,200 in professional fee revenue, leaving the hospital to contribute only a small fraction (about $200 per night) of the cost of each night shift. So night shifts typically require diminishing dollars of hospital support as the practice grows.

Unfortunately, any economy of scale for night-shift coverage usually is offset by inefficiencies and costs that larger practices incur—and small practices often don’t—such as a significant amount of management infrastructure, professional administration, dedicated physician leader time, and an information technology infrastructure. These resources often are necessary to manage the complexity of a large practice, but every practice should challenge itself to demonstrate that these things actually improve the practice’s efficiency and performance enough to justify the money spent on them.

Triage Pager

The larger the practice, the more likely there have been attempts to implement a triage pager system in which all new admissions and consults are routed to one pager (the triage, or “hot,” pager), which is held by one hospitalist at a time. In large practices, the “triage hospitalist” is usually so busy answering pages that they can do little else. And in many cases, ED doctors may describe a new admission to the triage hospitalist in detail only to have the triage hospitalist pass the information along to a colleague who will actually see the patient. This is an inefficient chain of communication, and I think most groups could do away with the triage pager. I described this issue in detail in my December 2008 column (“Technological Advance or Workplace Setback,” p. 69).

Unit-Based Assignment

Large hospitalist groups work in large hospitals and end up doing a lot of inefficient walking between nursing units during the day. They may have patients on 10 or more nursing units and end up spending only a little time on each unit, which probably diminishes the “constant availability” that most see as key to the hospitalist model. So many groups decide to have each hospitalist cover only a small number of nursing units. This really has become a hot topic in the past couple of years, and I discussed it in detail in my September 2007 column (“Unit-Based Hospitalist Practice,” p. 84).

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 Associates, a national hospitalist practice management consulting firm. He also is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Editor’s note: This is the second of a two-part series addressing issues at large HM groups.

Last month (“The Bigger They Are…,” May 2009, p. 58), I discussed the difficulty large HM groups (more than 20 full-time equivalent hospitalists) face in trying to ensure that nurses and other staff always know which hospitalist is attending a patient daily, as well as issues raised by the common practice of separating admitter and rounder shifts. This month, I want to address patient distribution and economic issues faced by large groups.

Patient Census

Large and small groups often work diligently to ensure all rounding doctors start the day with a nearly identical patient load. Such “load leveling” might take only a few minutes in groups of two or three rounding doctors, but it may take up to an hour a day if there are eight to 10 rounding doctors. Think about what this costs a large group. If a group has eight rounders spending the first 30 minutes of each day distributing patients, the practice is devoting 1,460 hours annually to this function. Those 1,460 hours equate to 0.7 FTE, and if each FTE costs the practice $220,000 annually in salary and benefits, then the practice is spending $154,000 per year to distribute patients each morning.

Is that the best way to use $154,000?

An alternative is to establish a system that allows the evening and night admitters to know in advance which rounding doctor will assume each patient’s care the next morning. The night/evening admitters would then write “admit to Dr. Satriani” for the first new admission, and “admit to Dr. Johnson” for the second, and so on. The hospital would never list evening/night admitters as a patient’s attending on the chart or in the computer. And each rounding doctor could arrive in the morning to find a list of new patients from overnight, eliminating the need for a meeting of all rounding doctors just to distribute the patients. There may be other reasons to meet each morning, such as case management rounds, but eliminating the need to spend time distributing patients will make the meetings shorter and get everyone out to the floors to see patients more quickly.

There are two simple ways the evening/night admitters can know how to assign new patients to the rounding doctors for the next morning. If the group wants to have each rounding doctor start with a nearly identical patient load, then the rounding doctors could indicate their load at the end of each day and the evening/night admitters would follow an algorithm of assigning the first admissions to the doctor who finished the prior day with a lighter load. The other option is for evening/night admitters to assign new patients through the night according to a fixed protocol, which wouldn’t vary based on the current patient load of each rounder. Of course, this will mean daily patient load could vary significantly from one rounder to the next, but over any long period, the workloads will tend to even out.

Elusive Economy of Scale

Hospitalists and hospital executives tend to have a different view of the benefits of practice growth to require more hospitalist FTEs. The hospitalists themselves often are convinced that when the group has more doctors, there will be more scheduling flexibility for each individual doctor, and perhaps each doctor will have to work fewer weekends. Sadly, neither is true to any significant degree in most practices. Some aspects of scheduling are easier when there are more doctors. For example, it usually is easier to find someone to fill in for an unexpected absence in larger groups. However, each doctor’s schedule usually doesn’t get much better or more flexible.

Hospital executives, or whoever is responsible for coming up with funding to support the practice, often look at a larger practice as one that can take advantage of economies of scale. For example, executives may project that when the practice is larger, the hospital’s contribution to the practice on a per-FTE or per-encounter basis will become smaller. But just like the elusive scheduling benefit of larger groups, few practices realize any economies of scale. The vast majority of the costs in most programs are provider labor costs, which scale with program volume. So in most cases, the larger a practice becomes, the larger the overall hospital financial support will be on a roughly linear basis.

More often than not, night-shift work does become more cost-effective as practices grow. For example, an in-house night shift for a practice of eight FTEs might generate $200 to $400 in collected professional fee revenue each night, leaving the hospital to pay the remaining $700 to $900 each night. (These numbers are for illustration and aren’t intended to represent benchmarks or realistic targets for any practice.) But as the practice grows to support 20 FTE hospitalists in total, nights get busier. The night doctor might average three or four admissions per night in an eight-FTE practice but could average 10 or more in a 20-FTE practice. Those 10 admissions might generate around $1,200 in professional fee revenue, leaving the hospital to contribute only a small fraction (about $200 per night) of the cost of each night shift. So night shifts typically require diminishing dollars of hospital support as the practice grows.

Unfortunately, any economy of scale for night-shift coverage usually is offset by inefficiencies and costs that larger practices incur—and small practices often don’t—such as a significant amount of management infrastructure, professional administration, dedicated physician leader time, and an information technology infrastructure. These resources often are necessary to manage the complexity of a large practice, but every practice should challenge itself to demonstrate that these things actually improve the practice’s efficiency and performance enough to justify the money spent on them.

Triage Pager

The larger the practice, the more likely there have been attempts to implement a triage pager system in which all new admissions and consults are routed to one pager (the triage, or “hot,” pager), which is held by one hospitalist at a time. In large practices, the “triage hospitalist” is usually so busy answering pages that they can do little else. And in many cases, ED doctors may describe a new admission to the triage hospitalist in detail only to have the triage hospitalist pass the information along to a colleague who will actually see the patient. This is an inefficient chain of communication, and I think most groups could do away with the triage pager. I described this issue in detail in my December 2008 column (“Technological Advance or Workplace Setback,” p. 69).

Unit-Based Assignment

Large hospitalist groups work in large hospitals and end up doing a lot of inefficient walking between nursing units during the day. They may have patients on 10 or more nursing units and end up spending only a little time on each unit, which probably diminishes the “constant availability” that most see as key to the hospitalist model. So many groups decide to have each hospitalist cover only a small number of nursing units. This really has become a hot topic in the past couple of years, and I discussed it in detail in my September 2007 column (“Unit-Based Hospitalist Practice,” p. 84).

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 Associates, a national hospitalist practice management consulting firm. He also is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Editor’s note: This is the second of a two-part series addressing issues at large HM groups.

Last month (“The Bigger They Are…,” May 2009, p. 58), I discussed the difficulty large HM groups (more than 20 full-time equivalent hospitalists) face in trying to ensure that nurses and other staff always know which hospitalist is attending a patient daily, as well as issues raised by the common practice of separating admitter and rounder shifts. This month, I want to address patient distribution and economic issues faced by large groups.

Patient Census

Large and small groups often work diligently to ensure all rounding doctors start the day with a nearly identical patient load. Such “load leveling” might take only a few minutes in groups of two or three rounding doctors, but it may take up to an hour a day if there are eight to 10 rounding doctors. Think about what this costs a large group. If a group has eight rounders spending the first 30 minutes of each day distributing patients, the practice is devoting 1,460 hours annually to this function. Those 1,460 hours equate to 0.7 FTE, and if each FTE costs the practice $220,000 annually in salary and benefits, then the practice is spending $154,000 per year to distribute patients each morning.

Is that the best way to use $154,000?

An alternative is to establish a system that allows the evening and night admitters to know in advance which rounding doctor will assume each patient’s care the next morning. The night/evening admitters would then write “admit to Dr. Satriani” for the first new admission, and “admit to Dr. Johnson” for the second, and so on. The hospital would never list evening/night admitters as a patient’s attending on the chart or in the computer. And each rounding doctor could arrive in the morning to find a list of new patients from overnight, eliminating the need for a meeting of all rounding doctors just to distribute the patients. There may be other reasons to meet each morning, such as case management rounds, but eliminating the need to spend time distributing patients will make the meetings shorter and get everyone out to the floors to see patients more quickly.

There are two simple ways the evening/night admitters can know how to assign new patients to the rounding doctors for the next morning. If the group wants to have each rounding doctor start with a nearly identical patient load, then the rounding doctors could indicate their load at the end of each day and the evening/night admitters would follow an algorithm of assigning the first admissions to the doctor who finished the prior day with a lighter load. The other option is for evening/night admitters to assign new patients through the night according to a fixed protocol, which wouldn’t vary based on the current patient load of each rounder. Of course, this will mean daily patient load could vary significantly from one rounder to the next, but over any long period, the workloads will tend to even out.

Elusive Economy of Scale

Hospitalists and hospital executives tend to have a different view of the benefits of practice growth to require more hospitalist FTEs. The hospitalists themselves often are convinced that when the group has more doctors, there will be more scheduling flexibility for each individual doctor, and perhaps each doctor will have to work fewer weekends. Sadly, neither is true to any significant degree in most practices. Some aspects of scheduling are easier when there are more doctors. For example, it usually is easier to find someone to fill in for an unexpected absence in larger groups. However, each doctor’s schedule usually doesn’t get much better or more flexible.

Hospital executives, or whoever is responsible for coming up with funding to support the practice, often look at a larger practice as one that can take advantage of economies of scale. For example, executives may project that when the practice is larger, the hospital’s contribution to the practice on a per-FTE or per-encounter basis will become smaller. But just like the elusive scheduling benefit of larger groups, few practices realize any economies of scale. The vast majority of the costs in most programs are provider labor costs, which scale with program volume. So in most cases, the larger a practice becomes, the larger the overall hospital financial support will be on a roughly linear basis.

More often than not, night-shift work does become more cost-effective as practices grow. For example, an in-house night shift for a practice of eight FTEs might generate $200 to $400 in collected professional fee revenue each night, leaving the hospital to pay the remaining $700 to $900 each night. (These numbers are for illustration and aren’t intended to represent benchmarks or realistic targets for any practice.) But as the practice grows to support 20 FTE hospitalists in total, nights get busier. The night doctor might average three or four admissions per night in an eight-FTE practice but could average 10 or more in a 20-FTE practice. Those 10 admissions might generate around $1,200 in professional fee revenue, leaving the hospital to contribute only a small fraction (about $200 per night) of the cost of each night shift. So night shifts typically require diminishing dollars of hospital support as the practice grows.

Unfortunately, any economy of scale for night-shift coverage usually is offset by inefficiencies and costs that larger practices incur—and small practices often don’t—such as a significant amount of management infrastructure, professional administration, dedicated physician leader time, and an information technology infrastructure. These resources often are necessary to manage the complexity of a large practice, but every practice should challenge itself to demonstrate that these things actually improve the practice’s efficiency and performance enough to justify the money spent on them.

Triage Pager

The larger the practice, the more likely there have been attempts to implement a triage pager system in which all new admissions and consults are routed to one pager (the triage, or “hot,” pager), which is held by one hospitalist at a time. In large practices, the “triage hospitalist” is usually so busy answering pages that they can do little else. And in many cases, ED doctors may describe a new admission to the triage hospitalist in detail only to have the triage hospitalist pass the information along to a colleague who will actually see the patient. This is an inefficient chain of communication, and I think most groups could do away with the triage pager. I described this issue in detail in my December 2008 column (“Technological Advance or Workplace Setback,” p. 69).

Unit-Based Assignment

Large hospitalist groups work in large hospitals and end up doing a lot of inefficient walking between nursing units during the day. They may have patients on 10 or more nursing units and end up spending only a little time on each unit, which probably diminishes the “constant availability” that most see as key to the hospitalist model. So many groups decide to have each hospitalist cover only a small number of nursing units. This really has become a hot topic in the past couple of years, and I discussed it in detail in my September 2007 column (“Unit-Based Hospitalist Practice,” p. 84).

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 Associates, a national hospitalist practice management consulting firm. He also is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

The world is atwitter over Twitter—the social networking utility that allows users to send immediate, 140-character text messages known as “tweets.” From then-presidential-nominee Barack Obama updating the masses on his campaign travels to actor Ashton Kutcher challenging the entire CNN news organization to a Twitter challenge (the former beat the latter by achieving 1 million Twitter followers first) to Britney Spears micro-blogging updates from her ever-so-fascinating life, Twitter is all the rage. The site describes its mission as allowing friends and family to stay connected through quick, frequent text answers to one question: “What are you doing?”

Not one to be left out, I thought I’d give it a shot. However, my tweeting ability is hamstrung by two serious insufficiencies: First, I’m a technology buffoon. Second, there’s no way I can keep my glorious insights to 140 characters.

So, with respect to the folks at Twitter, here’s a not-so-real-time chronicle of how I spent my time at HM09 in Chicago.

Us vs. Them?

The main session opened with a panel discussion about the future role of hospitalist leaders. The most poignant moment came when the panel of chief medical officers was asked how they viewed hospitalists. One recognized the tremendous potential hospitalists offer as the go-to resource for tackling important quality, efficiency, and process issues. This was countered by another participant warning that this potential can go untapped when HM group leaders function as “union stewards,” protecting hospitalists’ interests without a thought to the greater needs of the hospital. While recognizing advocacy as an important part of a group leader’s job, the message was clear: Too much advocacy can create an adversarial relationship that undermines our great potential. (That’s 769 characters.)

Laws Are Like Sausages: It’s Best Not to Watch Them Being Made

Mark Chassin, MD, MPP, MPH, president of The Joint Commission, discussed the quality revolution. He outlined the growing need and role of hospitalists in crossing the hospital quality chasm. He fired a cautionary shot across our bow by noting the increasing shortcomings of the public-private enterprise in improving healthcare quality. His clear concern is that if we don’t improve quality drastically, the government will step in and pass legislation—something that would most likely impact hospitals and hospitalists negatively. (532)

“Rack-da-poo”

A highly informative physician roundtable tackled value-based purchasing. The Reporting Hospital Quality Data for Annual Payment Update, or RHQDAPU—pronounced “rack-da-poo”—is a voluntary (insofar as hospitals who don’t comply lose 2% of Medicare reimbursement) hospital reporting system for adherence to core measures. This program, widely viewed as the foundation for future hospital pay for performance, will be a budget-neutral process such that some hospitals will win while an equal number will lose. Up to 5% of hospital reimbursement could be at risk. Data is available at www.hospital compare.gov. Check out your hospital; your patients already are. (659)

The Eagle Has Landed

At the end of the first day I co-chaired the Academic/Research special-interest forum with David Meltzer, MD, PhD, of the University of Chicago. The group grappled with a number of questions, from struggles with QI work to finding ways to support research to the development of young academicians. One comment, from Kim Eagle, MD, a world-renowned cardiologist at the University of Michigan and SHM’s visiting professor, resonated with the group. Dr. Eagle sagely responded to a young physician having difficulty developing a research interest by stating research is not about research but about answering questions. In the current healthcare environment, there are more than enough questions to launch all of our academic careers. (734)

Is HM Intensive Enough?

The second day got off to a roaring start with the best of the Research, Innovations and Clinical Vignettes (RIV). The most hotly anticipated research was from Emory University, where Kristin Wise, MD, and her colleagues evaluated an intensivist vs. hospitalist model for ICU staffing and found that after correction for baseline differences in acute illnesses, overall there were no differences in mortality between the two groups. Despite being constrained by methodological differences between the comparator groups and a lack of randomization, the data represents an important first step in addressing the huge shortfall of intensivist providers. (650)

Why My Wife Never Listens

Vinny Arora, MD, MA, of the University of Chicago and Erin R. Stucky, MD, of Rady Children’s Hospital in San Diego addressed the tremendously important topic of improving in-hospital handoffs. Part of the problem, they noted, is the egocentric heuristic. This cognitive shortcoming results in the sender believing that they are clearly expressing themselves because the message is apparent to them. Research shows that 40% of the time, the piece of information deemed most important by the sender is not identified as such by the recipient. Disconnect increases the better the sender knows the recipient, which explains much of our difficulty communicating in the hospital and domestically. Overcoming this requires vigilance on the sender’s part to be sure the message is accurately conveyed. (793)

Could We Go Bankrupt?

We all have too many patients and not enough providers. Thus, I was shocked when Scott F. Enderby, MD, of East Bay Physicians Medical Group in San Francisco spoke of a hospitalist group that went from profitability to bankruptcy in one year after adding four new employees. In his Finance 101 session, we learned how it happened despite an expected increase in clinical revenue: The group was constrained by a lack of liquidity that was retrospectively obvious from their balance sheet and operations and cash flow statements. Considering that more than a third of hospitalist directors do not know their group’s most basic financial metrics, this was a reminder that many more of us may be at risk in this increasingly unforgiving economy. (741)

Wachter’s World

As has become an annual meeting tradition, HM pioneer Robert Wachter, MD, FHM, professor and associate chairman of the department of medicine at the University of California at San Francisco, closed the meeting with his uniquely insightful comments on the state of healthcare. In using a case of mistaken identity he adeptly illustrated many of the key safety problems we face in healthcare. Further, he called for a transition away from a “no blame” medical culture to one of accountability. Once again, Dr. Wachter proved that despite going last, he continues to be out in front. (582)

A Child’s Calming Touch

This was my seventh consecutive annual meeting, and like the six before, it has exceeded my every expectation. From knowledge gained to the chance to speak and share my research to the opportunity to network and catch up with friends, the meeting was filled with lasting memories. Still, at times my hectic schedule bordered on chaos. It was during those times that I turned to a short, 23-second voicemail my wife sent the first day. On it my son, almost 2 years old, is belly-laughing as only a child can—pure, unbridled, carefree.

For me, it acted as a mariner, calming me at the end of a busy day, serving as a reminder of the important things in life, guiding me home. (674)

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

The world is atwitter over Twitter—the social networking utility that allows users to send immediate, 140-character text messages known as “tweets.” From then-presidential-nominee Barack Obama updating the masses on his campaign travels to actor Ashton Kutcher challenging the entire CNN news organization to a Twitter challenge (the former beat the latter by achieving 1 million Twitter followers first) to Britney Spears micro-blogging updates from her ever-so-fascinating life, Twitter is all the rage. The site describes its mission as allowing friends and family to stay connected through quick, frequent text answers to one question: “What are you doing?”

Not one to be left out, I thought I’d give it a shot. However, my tweeting ability is hamstrung by two serious insufficiencies: First, I’m a technology buffoon. Second, there’s no way I can keep my glorious insights to 140 characters.

So, with respect to the folks at Twitter, here’s a not-so-real-time chronicle of how I spent my time at HM09 in Chicago.

Us vs. Them?

The main session opened with a panel discussion about the future role of hospitalist leaders. The most poignant moment came when the panel of chief medical officers was asked how they viewed hospitalists. One recognized the tremendous potential hospitalists offer as the go-to resource for tackling important quality, efficiency, and process issues. This was countered by another participant warning that this potential can go untapped when HM group leaders function as “union stewards,” protecting hospitalists’ interests without a thought to the greater needs of the hospital. While recognizing advocacy as an important part of a group leader’s job, the message was clear: Too much advocacy can create an adversarial relationship that undermines our great potential. (That’s 769 characters.)

Laws Are Like Sausages: It’s Best Not to Watch Them Being Made

Mark Chassin, MD, MPP, MPH, president of The Joint Commission, discussed the quality revolution. He outlined the growing need and role of hospitalists in crossing the hospital quality chasm. He fired a cautionary shot across our bow by noting the increasing shortcomings of the public-private enterprise in improving healthcare quality. His clear concern is that if we don’t improve quality drastically, the government will step in and pass legislation—something that would most likely impact hospitals and hospitalists negatively. (532)

“Rack-da-poo”

A highly informative physician roundtable tackled value-based purchasing. The Reporting Hospital Quality Data for Annual Payment Update, or RHQDAPU—pronounced “rack-da-poo”—is a voluntary (insofar as hospitals who don’t comply lose 2% of Medicare reimbursement) hospital reporting system for adherence to core measures. This program, widely viewed as the foundation for future hospital pay for performance, will be a budget-neutral process such that some hospitals will win while an equal number will lose. Up to 5% of hospital reimbursement could be at risk. Data is available at www.hospital compare.gov. Check out your hospital; your patients already are. (659)

The Eagle Has Landed

At the end of the first day I co-chaired the Academic/Research special-interest forum with David Meltzer, MD, PhD, of the University of Chicago. The group grappled with a number of questions, from struggles with QI work to finding ways to support research to the development of young academicians. One comment, from Kim Eagle, MD, a world-renowned cardiologist at the University of Michigan and SHM’s visiting professor, resonated with the group. Dr. Eagle sagely responded to a young physician having difficulty developing a research interest by stating research is not about research but about answering questions. In the current healthcare environment, there are more than enough questions to launch all of our academic careers. (734)

Is HM Intensive Enough?

The second day got off to a roaring start with the best of the Research, Innovations and Clinical Vignettes (RIV). The most hotly anticipated research was from Emory University, where Kristin Wise, MD, and her colleagues evaluated an intensivist vs. hospitalist model for ICU staffing and found that after correction for baseline differences in acute illnesses, overall there were no differences in mortality between the two groups. Despite being constrained by methodological differences between the comparator groups and a lack of randomization, the data represents an important first step in addressing the huge shortfall of intensivist providers. (650)

Why My Wife Never Listens

Vinny Arora, MD, MA, of the University of Chicago and Erin R. Stucky, MD, of Rady Children’s Hospital in San Diego addressed the tremendously important topic of improving in-hospital handoffs. Part of the problem, they noted, is the egocentric heuristic. This cognitive shortcoming results in the sender believing that they are clearly expressing themselves because the message is apparent to them. Research shows that 40% of the time, the piece of information deemed most important by the sender is not identified as such by the recipient. Disconnect increases the better the sender knows the recipient, which explains much of our difficulty communicating in the hospital and domestically. Overcoming this requires vigilance on the sender’s part to be sure the message is accurately conveyed. (793)

Could We Go Bankrupt?

We all have too many patients and not enough providers. Thus, I was shocked when Scott F. Enderby, MD, of East Bay Physicians Medical Group in San Francisco spoke of a hospitalist group that went from profitability to bankruptcy in one year after adding four new employees. In his Finance 101 session, we learned how it happened despite an expected increase in clinical revenue: The group was constrained by a lack of liquidity that was retrospectively obvious from their balance sheet and operations and cash flow statements. Considering that more than a third of hospitalist directors do not know their group’s most basic financial metrics, this was a reminder that many more of us may be at risk in this increasingly unforgiving economy. (741)

Wachter’s World

As has become an annual meeting tradition, HM pioneer Robert Wachter, MD, FHM, professor and associate chairman of the department of medicine at the University of California at San Francisco, closed the meeting with his uniquely insightful comments on the state of healthcare. In using a case of mistaken identity he adeptly illustrated many of the key safety problems we face in healthcare. Further, he called for a transition away from a “no blame” medical culture to one of accountability. Once again, Dr. Wachter proved that despite going last, he continues to be out in front. (582)

A Child’s Calming Touch

This was my seventh consecutive annual meeting, and like the six before, it has exceeded my every expectation. From knowledge gained to the chance to speak and share my research to the opportunity to network and catch up with friends, the meeting was filled with lasting memories. Still, at times my hectic schedule bordered on chaos. It was during those times that I turned to a short, 23-second voicemail my wife sent the first day. On it my son, almost 2 years old, is belly-laughing as only a child can—pure, unbridled, carefree.

For me, it acted as a mariner, calming me at the end of a busy day, serving as a reminder of the important things in life, guiding me home. (674)

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

The world is atwitter over Twitter—the social networking utility that allows users to send immediate, 140-character text messages known as “tweets.” From then-presidential-nominee Barack Obama updating the masses on his campaign travels to actor Ashton Kutcher challenging the entire CNN news organization to a Twitter challenge (the former beat the latter by achieving 1 million Twitter followers first) to Britney Spears micro-blogging updates from her ever-so-fascinating life, Twitter is all the rage. The site describes its mission as allowing friends and family to stay connected through quick, frequent text answers to one question: “What are you doing?”

Not one to be left out, I thought I’d give it a shot. However, my tweeting ability is hamstrung by two serious insufficiencies: First, I’m a technology buffoon. Second, there’s no way I can keep my glorious insights to 140 characters.

So, with respect to the folks at Twitter, here’s a not-so-real-time chronicle of how I spent my time at HM09 in Chicago.

Us vs. Them?

The main session opened with a panel discussion about the future role of hospitalist leaders. The most poignant moment came when the panel of chief medical officers was asked how they viewed hospitalists. One recognized the tremendous potential hospitalists offer as the go-to resource for tackling important quality, efficiency, and process issues. This was countered by another participant warning that this potential can go untapped when HM group leaders function as “union stewards,” protecting hospitalists’ interests without a thought to the greater needs of the hospital. While recognizing advocacy as an important part of a group leader’s job, the message was clear: Too much advocacy can create an adversarial relationship that undermines our great potential. (That’s 769 characters.)

Laws Are Like Sausages: It’s Best Not to Watch Them Being Made

Mark Chassin, MD, MPP, MPH, president of The Joint Commission, discussed the quality revolution. He outlined the growing need and role of hospitalists in crossing the hospital quality chasm. He fired a cautionary shot across our bow by noting the increasing shortcomings of the public-private enterprise in improving healthcare quality. His clear concern is that if we don’t improve quality drastically, the government will step in and pass legislation—something that would most likely impact hospitals and hospitalists negatively. (532)

“Rack-da-poo”

A highly informative physician roundtable tackled value-based purchasing. The Reporting Hospital Quality Data for Annual Payment Update, or RHQDAPU—pronounced “rack-da-poo”—is a voluntary (insofar as hospitals who don’t comply lose 2% of Medicare reimbursement) hospital reporting system for adherence to core measures. This program, widely viewed as the foundation for future hospital pay for performance, will be a budget-neutral process such that some hospitals will win while an equal number will lose. Up to 5% of hospital reimbursement could be at risk. Data is available at www.hospital compare.gov. Check out your hospital; your patients already are. (659)

The Eagle Has Landed

At the end of the first day I co-chaired the Academic/Research special-interest forum with David Meltzer, MD, PhD, of the University of Chicago. The group grappled with a number of questions, from struggles with QI work to finding ways to support research to the development of young academicians. One comment, from Kim Eagle, MD, a world-renowned cardiologist at the University of Michigan and SHM’s visiting professor, resonated with the group. Dr. Eagle sagely responded to a young physician having difficulty developing a research interest by stating research is not about research but about answering questions. In the current healthcare environment, there are more than enough questions to launch all of our academic careers. (734)

Is HM Intensive Enough?

The second day got off to a roaring start with the best of the Research, Innovations and Clinical Vignettes (RIV). The most hotly anticipated research was from Emory University, where Kristin Wise, MD, and her colleagues evaluated an intensivist vs. hospitalist model for ICU staffing and found that after correction for baseline differences in acute illnesses, overall there were no differences in mortality between the two groups. Despite being constrained by methodological differences between the comparator groups and a lack of randomization, the data represents an important first step in addressing the huge shortfall of intensivist providers. (650)

Why My Wife Never Listens

Vinny Arora, MD, MA, of the University of Chicago and Erin R. Stucky, MD, of Rady Children’s Hospital in San Diego addressed the tremendously important topic of improving in-hospital handoffs. Part of the problem, they noted, is the egocentric heuristic. This cognitive shortcoming results in the sender believing that they are clearly expressing themselves because the message is apparent to them. Research shows that 40% of the time, the piece of information deemed most important by the sender is not identified as such by the recipient. Disconnect increases the better the sender knows the recipient, which explains much of our difficulty communicating in the hospital and domestically. Overcoming this requires vigilance on the sender’s part to be sure the message is accurately conveyed. (793)

Could We Go Bankrupt?

We all have too many patients and not enough providers. Thus, I was shocked when Scott F. Enderby, MD, of East Bay Physicians Medical Group in San Francisco spoke of a hospitalist group that went from profitability to bankruptcy in one year after adding four new employees. In his Finance 101 session, we learned how it happened despite an expected increase in clinical revenue: The group was constrained by a lack of liquidity that was retrospectively obvious from their balance sheet and operations and cash flow statements. Considering that more than a third of hospitalist directors do not know their group’s most basic financial metrics, this was a reminder that many more of us may be at risk in this increasingly unforgiving economy. (741)

Wachter’s World

As has become an annual meeting tradition, HM pioneer Robert Wachter, MD, FHM, professor and associate chairman of the department of medicine at the University of California at San Francisco, closed the meeting with his uniquely insightful comments on the state of healthcare. In using a case of mistaken identity he adeptly illustrated many of the key safety problems we face in healthcare. Further, he called for a transition away from a “no blame” medical culture to one of accountability. Once again, Dr. Wachter proved that despite going last, he continues to be out in front. (582)

A Child’s Calming Touch

This was my seventh consecutive annual meeting, and like the six before, it has exceeded my every expectation. From knowledge gained to the chance to speak and share my research to the opportunity to network and catch up with friends, the meeting was filled with lasting memories. Still, at times my hectic schedule bordered on chaos. It was during those times that I turned to a short, 23-second voicemail my wife sent the first day. On it my son, almost 2 years old, is belly-laughing as only a child can—pure, unbridled, carefree.

For me, it acted as a mariner, calming me at the end of a busy day, serving as a reminder of the important things in life, guiding me home. (674)

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

Let me start my first column as SHM president by introducing myself. I am an associate professor of medicine and the director of the hospital medicine program at the University of Michigan in Ann Arbor. I live in Ann Arbor with my family, which includes my wife, Juliet, and three young children. I also have a “professional family” at U of M, which includes 40 hospitalists and all the staff who facilitate the great work they do every day.

SHM, of course, is another big part of my extended family. I have been involved with SHM since 1997—when it was formed as the National Association of Inpatient Physi-cians (NAIP)—and have watched in awe its meteoric rise. What started as an organization with a handful of members and one staffer fully supported by the American College of Physicians (ACP) has grown into a fully independent society with more than 9,400 members and 50 employees. The growth in scope of SHM’s activities is no less impressive. In the mid-1990s, the society was focused on justifying the existence of a new breed of doctors called hospitalists.

Today, SHM is involved in multiple projects and programs designed to cement HM as the center of a healthcare system being redesigned to deliver high-quality, safe, efficient, and patient-centered healthcare.

Challenges Ahead

As exciting and ambitious as SHM’s goals are, there are innumerable challenges facing the field of HM that stand in its way. Let me touch on just a few.

The first and most obvious is the economy. This country is experiencing the worst recession it has seen in decades, and it is certainly affecting our hospitals. Here in Michigan, the plight of the auto industry graces the front pages of our newspapers daily (at least the papers that still exist). Hospitals that used to gloat about their high percentage of privately insured patients as a result of lucrative auto union contracts now see marked increases in public insurance—or no insurance at all.

Unfortunately, this is not just Michigan’s problem. Recent data suggest that more than 65% of the nation’s hospitals have seen increases in nonpaying patients and, as a result, marked declines in elective procedures and a bleak financial outlook. Many hospitalist programs are tied to the financial viability of their hospitals.

The decline in hospital resources also comes at a time when hospitals are being asked to invest more to promote safety and quality concurrent with growth in pay-for-performance programs and “no-pay” events, which make it clear that the financial picture could get even worse if these investments are not made.

The challenge in positioning hospitalists and HM at quality improvement (QI) ground zero—as we are doing—is that many of the systems and processes that require change extend beyond our usual range of control. The attention that has been given to reducing hospital readmissions by improving care transitions is a good example. It is not news that many bad things can—and often do—happen to patients after discharge. And many of the patients who suffer a post-discharge adverse event get readmitted.

It seems logical to have hospitalists fix the problem. But hospital readmissions are complex. As has been recently argued, some readmissions may even be a reflection of good quality—for example, if we capture a post-discharge problem and “save the patient” by readmitting them before they died at home.1 And to address preventable readmissions, systems must be developed to manage patients after they leave our hospitals, primary-care physicians need to be engaged to create effective ways to “receive” the post-discharge patient, and, finally, the decision to readmit—which often is made by the ED doctor or the PCP—needs to be addressed. This is not easy work.

Additionally, there are some challenges unique to academic hospitalists, a subset of our membership. Academic HM programs have been forced to grow at a dizzying speed in the past several years to keep up with increases in hospital discharges in an era of increased restrictions on the work hours of medical residents. These programs have grown by hiring many junior faculty with no advanced training in research, teaching, QI, or patient safety, let alone all the skills they need to bill, lead large teams, or manage complex hospital processes.

Of those problems, the most challenging, and arguably the most important to fix, is research training. To make lasting contributions to the practice of HM, rather than just implementing the practices, new treatments, and new care processes developed by other fields, HM needs to generate the new knowledge we use. That takes growing research, researchers, and sustainable academic programs. That, too, is not easy work.

HM Can Meet the Challenges

I am optimistic we can meet these myriad challenges, and I believe SHM is positioned to lead the charge. There is nothing we can do about the recession; hospitalists will have to weather the storm. Fortunately, HM has spent the last decade advocating not only its effectiveness, but also its cost-effectiveness. As a key hospital ally in the quality and safety wars, we are entrenched, and most hospital CEOs looking at ways to control costs should look beyond the core aspects of the local HM program. (They can take back my water cooler.)

It has not been lost on many at SHM that improving quality and safety at the hospital level requires engaging those outside our field. SHM is indeed tackling the daunting task of improving care transitions with its Project BOOST (Better Outcomes for Older Adults through Safe Transitions) program, but this comes after years of working with national quality organizations, policymakers, and other professional societies—including those that represent ED physicians and PCPs—in recognizing that fixing poor care transitions cannot be done by hospitalists alone.

Academic HM also is on SHM’s radar. The society, along with the Society of General Internal Medicine and the Association of Chiefs of General Internal Medicine, organized a summit to delineate and address the problems faced by academic HM. That meeting led to increased attention on the problems the field faces, enhanced advocacy at the federal level for research support, a “boot camp” designed for academic hospitalists to develop the skills they need to excel in an academic environment, and the beginnings of an SHM-funded faculty development research award.

All told, while there may be dark clouds on the horizon and rain in the forecast, SHM has spent years building a watertight organization and has foreseen many of the problems we now face. If we keep up the hard work, I am confident we, our patients, and the next generation of hospitalists will have brighter days ahead.

I look forward to the next year at the helm of SHM and am honored to represent SHM and its members, whose hard work and accomplishments never cease to amaze me.

Dr. Flanders is president of SHM.

Reference

1. Epstein AM. Revisiting readmissions—changing the incentives for shared accountability. N Engl J Med. 2009;360(14):1457-1459.

Let me start my first column as SHM president by introducing myself. I am an associate professor of medicine and the director of the hospital medicine program at the University of Michigan in Ann Arbor. I live in Ann Arbor with my family, which includes my wife, Juliet, and three young children. I also have a “professional family” at U of M, which includes 40 hospitalists and all the staff who facilitate the great work they do every day.

SHM, of course, is another big part of my extended family. I have been involved with SHM since 1997—when it was formed as the National Association of Inpatient Physi-cians (NAIP)—and have watched in awe its meteoric rise. What started as an organization with a handful of members and one staffer fully supported by the American College of Physicians (ACP) has grown into a fully independent society with more than 9,400 members and 50 employees. The growth in scope of SHM’s activities is no less impressive. In the mid-1990s, the society was focused on justifying the existence of a new breed of doctors called hospitalists.

Today, SHM is involved in multiple projects and programs designed to cement HM as the center of a healthcare system being redesigned to deliver high-quality, safe, efficient, and patient-centered healthcare.

Challenges Ahead

As exciting and ambitious as SHM’s goals are, there are innumerable challenges facing the field of HM that stand in its way. Let me touch on just a few.

The first and most obvious is the economy. This country is experiencing the worst recession it has seen in decades, and it is certainly affecting our hospitals. Here in Michigan, the plight of the auto industry graces the front pages of our newspapers daily (at least the papers that still exist). Hospitals that used to gloat about their high percentage of privately insured patients as a result of lucrative auto union contracts now see marked increases in public insurance—or no insurance at all.

Unfortunately, this is not just Michigan’s problem. Recent data suggest that more than 65% of the nation’s hospitals have seen increases in nonpaying patients and, as a result, marked declines in elective procedures and a bleak financial outlook. Many hospitalist programs are tied to the financial viability of their hospitals.

The decline in hospital resources also comes at a time when hospitals are being asked to invest more to promote safety and quality concurrent with growth in pay-for-performance programs and “no-pay” events, which make it clear that the financial picture could get even worse if these investments are not made.

The challenge in positioning hospitalists and HM at quality improvement (QI) ground zero—as we are doing—is that many of the systems and processes that require change extend beyond our usual range of control. The attention that has been given to reducing hospital readmissions by improving care transitions is a good example. It is not news that many bad things can—and often do—happen to patients after discharge. And many of the patients who suffer a post-discharge adverse event get readmitted.

It seems logical to have hospitalists fix the problem. But hospital readmissions are complex. As has been recently argued, some readmissions may even be a reflection of good quality—for example, if we capture a post-discharge problem and “save the patient” by readmitting them before they died at home.1 And to address preventable readmissions, systems must be developed to manage patients after they leave our hospitals, primary-care physicians need to be engaged to create effective ways to “receive” the post-discharge patient, and, finally, the decision to readmit—which often is made by the ED doctor or the PCP—needs to be addressed. This is not easy work.

Additionally, there are some challenges unique to academic hospitalists, a subset of our membership. Academic HM programs have been forced to grow at a dizzying speed in the past several years to keep up with increases in hospital discharges in an era of increased restrictions on the work hours of medical residents. These programs have grown by hiring many junior faculty with no advanced training in research, teaching, QI, or patient safety, let alone all the skills they need to bill, lead large teams, or manage complex hospital processes.

Of those problems, the most challenging, and arguably the most important to fix, is research training. To make lasting contributions to the practice of HM, rather than just implementing the practices, new treatments, and new care processes developed by other fields, HM needs to generate the new knowledge we use. That takes growing research, researchers, and sustainable academic programs. That, too, is not easy work.

HM Can Meet the Challenges

I am optimistic we can meet these myriad challenges, and I believe SHM is positioned to lead the charge. There is nothing we can do about the recession; hospitalists will have to weather the storm. Fortunately, HM has spent the last decade advocating not only its effectiveness, but also its cost-effectiveness. As a key hospital ally in the quality and safety wars, we are entrenched, and most hospital CEOs looking at ways to control costs should look beyond the core aspects of the local HM program. (They can take back my water cooler.)

It has not been lost on many at SHM that improving quality and safety at the hospital level requires engaging those outside our field. SHM is indeed tackling the daunting task of improving care transitions with its Project BOOST (Better Outcomes for Older Adults through Safe Transitions) program, but this comes after years of working with national quality organizations, policymakers, and other professional societies—including those that represent ED physicians and PCPs—in recognizing that fixing poor care transitions cannot be done by hospitalists alone.

Academic HM also is on SHM’s radar. The society, along with the Society of General Internal Medicine and the Association of Chiefs of General Internal Medicine, organized a summit to delineate and address the problems faced by academic HM. That meeting led to increased attention on the problems the field faces, enhanced advocacy at the federal level for research support, a “boot camp” designed for academic hospitalists to develop the skills they need to excel in an academic environment, and the beginnings of an SHM-funded faculty development research award.

All told, while there may be dark clouds on the horizon and rain in the forecast, SHM has spent years building a watertight organization and has foreseen many of the problems we now face. If we keep up the hard work, I am confident we, our patients, and the next generation of hospitalists will have brighter days ahead.

I look forward to the next year at the helm of SHM and am honored to represent SHM and its members, whose hard work and accomplishments never cease to amaze me.

Dr. Flanders is president of SHM.

Reference

1. Epstein AM. Revisiting readmissions—changing the incentives for shared accountability. N Engl J Med. 2009;360(14):1457-1459.

Let me start my first column as SHM president by introducing myself. I am an associate professor of medicine and the director of the hospital medicine program at the University of Michigan in Ann Arbor. I live in Ann Arbor with my family, which includes my wife, Juliet, and three young children. I also have a “professional family” at U of M, which includes 40 hospitalists and all the staff who facilitate the great work they do every day.

SHM, of course, is another big part of my extended family. I have been involved with SHM since 1997—when it was formed as the National Association of Inpatient Physi-cians (NAIP)—and have watched in awe its meteoric rise. What started as an organization with a handful of members and one staffer fully supported by the American College of Physicians (ACP) has grown into a fully independent society with more than 9,400 members and 50 employees. The growth in scope of SHM’s activities is no less impressive. In the mid-1990s, the society was focused on justifying the existence of a new breed of doctors called hospitalists.

Today, SHM is involved in multiple projects and programs designed to cement HM as the center of a healthcare system being redesigned to deliver high-quality, safe, efficient, and patient-centered healthcare.

Challenges Ahead

As exciting and ambitious as SHM’s goals are, there are innumerable challenges facing the field of HM that stand in its way. Let me touch on just a few.

The first and most obvious is the economy. This country is experiencing the worst recession it has seen in decades, and it is certainly affecting our hospitals. Here in Michigan, the plight of the auto industry graces the front pages of our newspapers daily (at least the papers that still exist). Hospitals that used to gloat about their high percentage of privately insured patients as a result of lucrative auto union contracts now see marked increases in public insurance—or no insurance at all.

Unfortunately, this is not just Michigan’s problem. Recent data suggest that more than 65% of the nation’s hospitals have seen increases in nonpaying patients and, as a result, marked declines in elective procedures and a bleak financial outlook. Many hospitalist programs are tied to the financial viability of their hospitals.

The decline in hospital resources also comes at a time when hospitals are being asked to invest more to promote safety and quality concurrent with growth in pay-for-performance programs and “no-pay” events, which make it clear that the financial picture could get even worse if these investments are not made.

The challenge in positioning hospitalists and HM at quality improvement (QI) ground zero—as we are doing—is that many of the systems and processes that require change extend beyond our usual range of control. The attention that has been given to reducing hospital readmissions by improving care transitions is a good example. It is not news that many bad things can—and often do—happen to patients after discharge. And many of the patients who suffer a post-discharge adverse event get readmitted.

It seems logical to have hospitalists fix the problem. But hospital readmissions are complex. As has been recently argued, some readmissions may even be a reflection of good quality—for example, if we capture a post-discharge problem and “save the patient” by readmitting them before they died at home.1 And to address preventable readmissions, systems must be developed to manage patients after they leave our hospitals, primary-care physicians need to be engaged to create effective ways to “receive” the post-discharge patient, and, finally, the decision to readmit—which often is made by the ED doctor or the PCP—needs to be addressed. This is not easy work.

Additionally, there are some challenges unique to academic hospitalists, a subset of our membership. Academic HM programs have been forced to grow at a dizzying speed in the past several years to keep up with increases in hospital discharges in an era of increased restrictions on the work hours of medical residents. These programs have grown by hiring many junior faculty with no advanced training in research, teaching, QI, or patient safety, let alone all the skills they need to bill, lead large teams, or manage complex hospital processes.

Of those problems, the most challenging, and arguably the most important to fix, is research training. To make lasting contributions to the practice of HM, rather than just implementing the practices, new treatments, and new care processes developed by other fields, HM needs to generate the new knowledge we use. That takes growing research, researchers, and sustainable academic programs. That, too, is not easy work.

HM Can Meet the Challenges

I am optimistic we can meet these myriad challenges, and I believe SHM is positioned to lead the charge. There is nothing we can do about the recession; hospitalists will have to weather the storm. Fortunately, HM has spent the last decade advocating not only its effectiveness, but also its cost-effectiveness. As a key hospital ally in the quality and safety wars, we are entrenched, and most hospital CEOs looking at ways to control costs should look beyond the core aspects of the local HM program. (They can take back my water cooler.)

It has not been lost on many at SHM that improving quality and safety at the hospital level requires engaging those outside our field. SHM is indeed tackling the daunting task of improving care transitions with its Project BOOST (Better Outcomes for Older Adults through Safe Transitions) program, but this comes after years of working with national quality organizations, policymakers, and other professional societies—including those that represent ED physicians and PCPs—in recognizing that fixing poor care transitions cannot be done by hospitalists alone.

Academic HM also is on SHM’s radar. The society, along with the Society of General Internal Medicine and the Association of Chiefs of General Internal Medicine, organized a summit to delineate and address the problems faced by academic HM. That meeting led to increased attention on the problems the field faces, enhanced advocacy at the federal level for research support, a “boot camp” designed for academic hospitalists to develop the skills they need to excel in an academic environment, and the beginnings of an SHM-funded faculty development research award.

All told, while there may be dark clouds on the horizon and rain in the forecast, SHM has spent years building a watertight organization and has foreseen many of the problems we now face. If we keep up the hard work, I am confident we, our patients, and the next generation of hospitalists will have brighter days ahead.

I look forward to the next year at the helm of SHM and am honored to represent SHM and its members, whose hard work and accomplishments never cease to amaze me.

Dr. Flanders is president of SHM.

Reference

1. Epstein AM. Revisiting readmissions—changing the incentives for shared accountability. N Engl J Med. 2009;360(14):1457-1459.

Mercy Medical Center in Springfield, Mass., has enjoyed a number of distinctions in its brief HM history. The 182-bed acute-care institution was one of the first to use the term hospitalist. Its C-suite was among the first to subsidize an HM group. And one of its physicians is a co-founder of SHM.

So it was only natural that Amanda Wilson, MD, FHM, wanted Mercy’s staff—including HM pioneer Winthrop F. Whitcomb, MD, FHM—to be among the first hospitalists in the country honored with SHM’s new Fellow of Hospital Medicine (FHM) designation. The first class of fellows was inducted at HM09 in Chicago.

“It’s inspiring to me,” says Dr. Wilson, chief of medicine and medical director of the hospitalist program at Mercy Medical Center. “It’s about how many people are lifelong, committed hospitalists. It’s a recognition [that] it’s a real specialty.”

A Select Few

The inaugural group of fellows numbers 514, roughly 5% of SHM total membership, but only about 2% of the estimated 28,000 hospitalists currently practicing. More than 600 hospitalists applied for the designation. To be eligible, candidates must have a minimum of five years as a practicing hospitalist, no serious disciplinary action in the past five years, and the endorsement of two active SHM members.

Hospitalists who have taken on added responsibilities at their institutions, including involvement in quality initiatives and a commitment to continuing education, are especially encouraged to apply. All of the FHM values are reflected in a pledge the group took before about 1,600 colleagues at HM09 in Chicago.

“I make the following pledge,” the testimony reads in part, “to consistently strive to provide the highest quality care for all my patients … to foster interdisciplinary teamwork that integrates hospital systems … and to conduct myself in a manner becoming of a Fellow in Hospital Medicine.”

Recognition and Respect

The FHM is the first step in the society’s plan to incorporate several levels of designations to recognize hospitalist contributions. The next level will be a Senior Fellow in Hospital Medicine (SFHM); the final rung on the ladder will be a Master in Hospital Medicine (MHM). Criteria for those programs will be unveiled soon, and the first SFHM class will be inducted at HM10 in Washington, D.C.

Organizers say it’s likely that only a percentage of the first class of fellows will move to the second level right away. The American Board of Internal Med-icine anticipates that a focused-practice program could open for qualified candidates in 2010 or 2011.

Still, freshman fellows see the FHM designation as a step forward—for both individual hospitalists and SHM.

“It’s recognition you went above and beyond just punching the clock,” says Kerry Moore, MD, FHM, co-chief of the Sound Inpatient Physicians hospitalist group at St. Anthony Central Hospital in Denver. “We don’t just have a meeting; we’re a society and we offer levels of recognition.”

Dr. Wilson says the FHM designation will add a level of respect to the HM specialty and should be just as important to physicians in other specialties as it will be to HM stalwarts. “Up until now,” she says, “you’re a glorified resident, in their opinion.”

Andrea Darilek, MD, FAAP, FHM, agrees the FHM designation should confer an added level of admiration to the hospitalist profession, especially for those like her who have never worked in another specialty. Dr. Darilek, vice chair of the department of hospital medicine at the Billings Clinic in Montana, has been a hospitalist for eight years. “All other fields of medicine have this,” she says. “If you go to a surgery convention, everyone has membership in a society of surgery. It’s important for hospitalists to have national recognition.”

Bijo Chacko, MD, FHM, says it’s particularly meaningful to be part of the first corps of fellows because it includes some of the most recognizable names in HM. He also noted that future fellows could view this class as “trailblazers.” “It shows the penetration of the field,” says Dr. Chacko, hospital medicine director for Preferred Health Partners, which staffs four sites in Brooklyn, N.Y. “The expertise and the physician base is growing enough [that] it warrants a designation.”

The FHM designation doesn’t yet have the familiar ring of such titles as FACP, MPH, or MBA. The sheen is still so new that many in the healthcare industry are likely going to need a while to get used to it, jokes Jack Childress, MD, FHM, a hospitalist at Christus St. Michael Hospital in Texarkana, Texas. That could be seen as an advantage in spreading the word about how much the field of HM has grown, Dr. Childress notes.

“If they see the [letters], they probably have no idea what it means,” he says. “They’ll be asking a lot of questions.”

What better spokesperson for HM than a fellow? TH

Richard Quinn is a freelance writer based in New Jersey.

Mercy Medical Center in Springfield, Mass., has enjoyed a number of distinctions in its brief HM history. The 182-bed acute-care institution was one of the first to use the term hospitalist. Its C-suite was among the first to subsidize an HM group. And one of its physicians is a co-founder of SHM.

So it was only natural that Amanda Wilson, MD, FHM, wanted Mercy’s staff—including HM pioneer Winthrop F. Whitcomb, MD, FHM—to be among the first hospitalists in the country honored with SHM’s new Fellow of Hospital Medicine (FHM) designation. The first class of fellows was inducted at HM09 in Chicago.

“It’s inspiring to me,” says Dr. Wilson, chief of medicine and medical director of the hospitalist program at Mercy Medical Center. “It’s about how many people are lifelong, committed hospitalists. It’s a recognition [that] it’s a real specialty.”

A Select Few

The inaugural group of fellows numbers 514, roughly 5% of SHM total membership, but only about 2% of the estimated 28,000 hospitalists currently practicing. More than 600 hospitalists applied for the designation. To be eligible, candidates must have a minimum of five years as a practicing hospitalist, no serious disciplinary action in the past five years, and the endorsement of two active SHM members.

Hospitalists who have taken on added responsibilities at their institutions, including involvement in quality initiatives and a commitment to continuing education, are especially encouraged to apply. All of the FHM values are reflected in a pledge the group took before about 1,600 colleagues at HM09 in Chicago.

“I make the following pledge,” the testimony reads in part, “to consistently strive to provide the highest quality care for all my patients … to foster interdisciplinary teamwork that integrates hospital systems … and to conduct myself in a manner becoming of a Fellow in Hospital Medicine.”

Recognition and Respect

The FHM is the first step in the society’s plan to incorporate several levels of designations to recognize hospitalist contributions. The next level will be a Senior Fellow in Hospital Medicine (SFHM); the final rung on the ladder will be a Master in Hospital Medicine (MHM). Criteria for those programs will be unveiled soon, and the first SFHM class will be inducted at HM10 in Washington, D.C.

Organizers say it’s likely that only a percentage of the first class of fellows will move to the second level right away. The American Board of Internal Med-icine anticipates that a focused-practice program could open for qualified candidates in 2010 or 2011.

Still, freshman fellows see the FHM designation as a step forward—for both individual hospitalists and SHM.

“It’s recognition you went above and beyond just punching the clock,” says Kerry Moore, MD, FHM, co-chief of the Sound Inpatient Physicians hospitalist group at St. Anthony Central Hospital in Denver. “We don’t just have a meeting; we’re a society and we offer levels of recognition.”

Dr. Wilson says the FHM designation will add a level of respect to the HM specialty and should be just as important to physicians in other specialties as it will be to HM stalwarts. “Up until now,” she says, “you’re a glorified resident, in their opinion.”

Andrea Darilek, MD, FAAP, FHM, agrees the FHM designation should confer an added level of admiration to the hospitalist profession, especially for those like her who have never worked in another specialty. Dr. Darilek, vice chair of the department of hospital medicine at the Billings Clinic in Montana, has been a hospitalist for eight years. “All other fields of medicine have this,” she says. “If you go to a surgery convention, everyone has membership in a society of surgery. It’s important for hospitalists to have national recognition.”

Bijo Chacko, MD, FHM, says it’s particularly meaningful to be part of the first corps of fellows because it includes some of the most recognizable names in HM. He also noted that future fellows could view this class as “trailblazers.” “It shows the penetration of the field,” says Dr. Chacko, hospital medicine director for Preferred Health Partners, which staffs four sites in Brooklyn, N.Y. “The expertise and the physician base is growing enough [that] it warrants a designation.”

The FHM designation doesn’t yet have the familiar ring of such titles as FACP, MPH, or MBA. The sheen is still so new that many in the healthcare industry are likely going to need a while to get used to it, jokes Jack Childress, MD, FHM, a hospitalist at Christus St. Michael Hospital in Texarkana, Texas. That could be seen as an advantage in spreading the word about how much the field of HM has grown, Dr. Childress notes.

“If they see the [letters], they probably have no idea what it means,” he says. “They’ll be asking a lot of questions.”

What better spokesperson for HM than a fellow? TH

Richard Quinn is a freelance writer based in New Jersey.

Mercy Medical Center in Springfield, Mass., has enjoyed a number of distinctions in its brief HM history. The 182-bed acute-care institution was one of the first to use the term hospitalist. Its C-suite was among the first to subsidize an HM group. And one of its physicians is a co-founder of SHM.

So it was only natural that Amanda Wilson, MD, FHM, wanted Mercy’s staff—including HM pioneer Winthrop F. Whitcomb, MD, FHM—to be among the first hospitalists in the country honored with SHM’s new Fellow of Hospital Medicine (FHM) designation. The first class of fellows was inducted at HM09 in Chicago.

“It’s inspiring to me,” says Dr. Wilson, chief of medicine and medical director of the hospitalist program at Mercy Medical Center. “It’s about how many people are lifelong, committed hospitalists. It’s a recognition [that] it’s a real specialty.”

A Select Few

The inaugural group of fellows numbers 514, roughly 5% of SHM total membership, but only about 2% of the estimated 28,000 hospitalists currently practicing. More than 600 hospitalists applied for the designation. To be eligible, candidates must have a minimum of five years as a practicing hospitalist, no serious disciplinary action in the past five years, and the endorsement of two active SHM members.

Hospitalists who have taken on added responsibilities at their institutions, including involvement in quality initiatives and a commitment to continuing education, are especially encouraged to apply. All of the FHM values are reflected in a pledge the group took before about 1,600 colleagues at HM09 in Chicago.

“I make the following pledge,” the testimony reads in part, “to consistently strive to provide the highest quality care for all my patients … to foster interdisciplinary teamwork that integrates hospital systems … and to conduct myself in a manner becoming of a Fellow in Hospital Medicine.”

Recognition and Respect

The FHM is the first step in the society’s plan to incorporate several levels of designations to recognize hospitalist contributions. The next level will be a Senior Fellow in Hospital Medicine (SFHM); the final rung on the ladder will be a Master in Hospital Medicine (MHM). Criteria for those programs will be unveiled soon, and the first SFHM class will be inducted at HM10 in Washington, D.C.

Organizers say it’s likely that only a percentage of the first class of fellows will move to the second level right away. The American Board of Internal Med-icine anticipates that a focused-practice program could open for qualified candidates in 2010 or 2011.

Still, freshman fellows see the FHM designation as a step forward—for both individual hospitalists and SHM.

“It’s recognition you went above and beyond just punching the clock,” says Kerry Moore, MD, FHM, co-chief of the Sound Inpatient Physicians hospitalist group at St. Anthony Central Hospital in Denver. “We don’t just have a meeting; we’re a society and we offer levels of recognition.”

Dr. Wilson says the FHM designation will add a level of respect to the HM specialty and should be just as important to physicians in other specialties as it will be to HM stalwarts. “Up until now,” she says, “you’re a glorified resident, in their opinion.”

Andrea Darilek, MD, FAAP, FHM, agrees the FHM designation should confer an added level of admiration to the hospitalist profession, especially for those like her who have never worked in another specialty. Dr. Darilek, vice chair of the department of hospital medicine at the Billings Clinic in Montana, has been a hospitalist for eight years. “All other fields of medicine have this,” she says. “If you go to a surgery convention, everyone has membership in a society of surgery. It’s important for hospitalists to have national recognition.”

Bijo Chacko, MD, FHM, says it’s particularly meaningful to be part of the first corps of fellows because it includes some of the most recognizable names in HM. He also noted that future fellows could view this class as “trailblazers.” “It shows the penetration of the field,” says Dr. Chacko, hospital medicine director for Preferred Health Partners, which staffs four sites in Brooklyn, N.Y. “The expertise and the physician base is growing enough [that] it warrants a designation.”

The FHM designation doesn’t yet have the familiar ring of such titles as FACP, MPH, or MBA. The sheen is still so new that many in the healthcare industry are likely going to need a while to get used to it, jokes Jack Childress, MD, FHM, a hospitalist at Christus St. Michael Hospital in Texarkana, Texas. That could be seen as an advantage in spreading the word about how much the field of HM has grown, Dr. Childress notes.

“If they see the [letters], they probably have no idea what it means,” he says. “They’ll be asking a lot of questions.”

What better spokesperson for HM than a fellow? TH

Richard Quinn is a freelance writer based in New Jersey.

SHM has announced the annual Awards of Excellence to hospitalists on the leading edge of the specialty. The honors recognize accomplishments in education, research, clinical care, service, and quality improvement (QI). The praises are as varied as the recipients: They hail from Wisconsin to Pennsylvania, Minnesota to North Carolina.

This year’s awards, presented at the annual President’s Luncheon at HM09 in Chicago, went to:

Award for Excellence in Teaching

Eric Howell, MD, FHM

Johns Hopkins Bayview Medical Center, Baltimore

Dr. Howell is an admitted introvert, so one might assume teaching isn’t the most natural application of his medical talents. But when he became chief resident at Johns Hopkins in 1999, he was forced to lead weekly education sessions. The next year, it was weekly didactic classes as an instructor. Five years later, he made assistant professor; this year he moved up again, to associate professor.

“It’s certainly not my fund of knowledge,” Dr. Howell says. “Students and I enjoy interacting because I enjoy it and I make it fun. What little knowledge I have, I pass on well.”

Dr. Howell’s laid-back style—he asks students to call him Eric, although they rarely do—serves him well in the classroom setting. However, the other hats he wears—as Bayview Medical Center’s hospitalist division director and faculty leader at Helen B. Taussig College—limit his teaching time. In a way, it’s what helped him win the award.

“Because I have many other things to do, [teaching] stays special,” says Dr. Howell, who recently joined SHM’s Board of Directors. “It’s a nice reprieve from some of the other high-pressure things, like treating a sick patient, problem-solving for my hospital, or keeping my hospitalist group running.”

Excellence in Research Award

Samir Shah, MD, MSCE, FHM

Children’s Hospital of Philadelphia

Most medical students don’t set out to be hailed as researchers, and Dr. Shah is no exception. Still, in order to graduate from the Yale University School of Medicine, every student has to complete a research project. The research bug bit Dr. Shah, and he stayed an extra year at Yale to pursue teaching and research interests. Now he’s a leading voice for pediatric hospitalists, an assistant professor of pediatrics and epidemiology at the University of Pennsylvania Medical School of Medicine, and an attending physician at Children’s Hospital of Philadelphia.

“It’s the feeling of making a difference not in the life of one child but the lives of many children,” he says. “To say I fundamentally had an impact on the way we view a disease … that’s a different feeling altogether.”

Dr. Shah’s research has focused on improved management of patients with common childhood infections, particularly pneumonia and meningitis. His research is published regularly, and he serves as editor or co-editor for several journals.

“The goal of our research is to influence policy or clinical practice,” Dr Shah says. “Ideally, both.”

Award for Outstanding Service in HM

Eric Siegal, MD, FHM

University of Wisconsin School of Medicine and Public Health, Madison

Dr. Siegal has been the head of SHM’s Public Policy Committee for nearly four years, and while he jokes that no one else is dumb enough to take on the role, it’s exactly that kind of experience that has earned him the society’s “utility infielder award.”

“It’s gotten harder,” Dr. Siegal says of HM advocacy. “Now that people know what SHM is ... it’s going to get a lot harder, in a good way.”

SHM leaders say Dr. Siegal’s grasp of issues is vital as the federal government weighs the most significant healthcare reform in decades and hospitals struggle to balance costs and efficiency against the push to improve quality of care.

In fact, Dr. Siegal’s reputation within the society is so respected he was co-nominated for this year’s service award by Laura Allendorf, SHM’s senior advisor on advocacy and government affairs. Dr. Siegal currently is a critical-care fellow in Madison, and previously served as regional medical director for Cogent Healthcare.

Award for Clinical Excellence

Jerome Siy, MD, FHM

Regions Hospital, Saint Paul, Minn.

Dr. Siy wants to collaborate on pretty much everything. It doesn’t matter if he’s developing an HM platform that employs nearly 50 hospitalists, teaching at the University of Minnesota Medical School, or creating an interdisciplinary program that pulls together hospitalists, ED physicians, and behavioral health doctors.

“Nothing is successful when one person does all the work,” Dr. Siy says. “It doesn’t help just having department heads in a room. You need the people who are actually working.”

Dr. Siy’s work as chief of hospital medicine at Regions drew industry-wide attention, namely for the program he developed to carve out 96 inpatient mental-health beds to streamline intake and discharge processes. And even though he also directs a fellowship program for HealthPartners Medical Group in Saint Paul, Dr. Siy views his award as a testament to his colleagues.

“When you’re part of a team that you really enjoy, the work becomes easier,” Dr. Siy says. “I feel like it’s an acknowledgement of the way we all work together.” TH

Richard Quinn is a freelance writer based in New Jersey.

SHM has announced the annual Awards of Excellence to hospitalists on the leading edge of the specialty. The honors recognize accomplishments in education, research, clinical care, service, and quality improvement (QI). The praises are as varied as the recipients: They hail from Wisconsin to Pennsylvania, Minnesota to North Carolina.

This year’s awards, presented at the annual President’s Luncheon at HM09 in Chicago, went to:

Award for Excellence in Teaching

Eric Howell, MD, FHM

Johns Hopkins Bayview Medical Center, Baltimore

Dr. Howell is an admitted introvert, so one might assume teaching isn’t the most natural application of his medical talents. But when he became chief resident at Johns Hopkins in 1999, he was forced to lead weekly education sessions. The next year, it was weekly didactic classes as an instructor. Five years later, he made assistant professor; this year he moved up again, to associate professor.

“It’s certainly not my fund of knowledge,” Dr. Howell says. “Students and I enjoy interacting because I enjoy it and I make it fun. What little knowledge I have, I pass on well.”

Dr. Howell’s laid-back style—he asks students to call him Eric, although they rarely do—serves him well in the classroom setting. However, the other hats he wears—as Bayview Medical Center’s hospitalist division director and faculty leader at Helen B. Taussig College—limit his teaching time. In a way, it’s what helped him win the award.

“Because I have many other things to do, [teaching] stays special,” says Dr. Howell, who recently joined SHM’s Board of Directors. “It’s a nice reprieve from some of the other high-pressure things, like treating a sick patient, problem-solving for my hospital, or keeping my hospitalist group running.”

Excellence in Research Award

Samir Shah, MD, MSCE, FHM

Children’s Hospital of Philadelphia

Most medical students don’t set out to be hailed as researchers, and Dr. Shah is no exception. Still, in order to graduate from the Yale University School of Medicine, every student has to complete a research project. The research bug bit Dr. Shah, and he stayed an extra year at Yale to pursue teaching and research interests. Now he’s a leading voice for pediatric hospitalists, an assistant professor of pediatrics and epidemiology at the University of Pennsylvania Medical School of Medicine, and an attending physician at Children’s Hospital of Philadelphia.

“It’s the feeling of making a difference not in the life of one child but the lives of many children,” he says. “To say I fundamentally had an impact on the way we view a disease … that’s a different feeling altogether.”

Dr. Shah’s research has focused on improved management of patients with common childhood infections, particularly pneumonia and meningitis. His research is published regularly, and he serves as editor or co-editor for several journals.

“The goal of our research is to influence policy or clinical practice,” Dr Shah says. “Ideally, both.”

Award for Outstanding Service in HM

Eric Siegal, MD, FHM

University of Wisconsin School of Medicine and Public Health, Madison

Dr. Siegal has been the head of SHM’s Public Policy Committee for nearly four years, and while he jokes that no one else is dumb enough to take on the role, it’s exactly that kind of experience that has earned him the society’s “utility infielder award.”

“It’s gotten harder,” Dr. Siegal says of HM advocacy. “Now that people know what SHM is ... it’s going to get a lot harder, in a good way.”

SHM leaders say Dr. Siegal’s grasp of issues is vital as the federal government weighs the most significant healthcare reform in decades and hospitals struggle to balance costs and efficiency against the push to improve quality of care.

In fact, Dr. Siegal’s reputation within the society is so respected he was co-nominated for this year’s service award by Laura Allendorf, SHM’s senior advisor on advocacy and government affairs. Dr. Siegal currently is a critical-care fellow in Madison, and previously served as regional medical director for Cogent Healthcare.

Award for Clinical Excellence

Jerome Siy, MD, FHM

Regions Hospital, Saint Paul, Minn.

Dr. Siy wants to collaborate on pretty much everything. It doesn’t matter if he’s developing an HM platform that employs nearly 50 hospitalists, teaching at the University of Minnesota Medical School, or creating an interdisciplinary program that pulls together hospitalists, ED physicians, and behavioral health doctors.

“Nothing is successful when one person does all the work,” Dr. Siy says. “It doesn’t help just having department heads in a room. You need the people who are actually working.”

Dr. Siy’s work as chief of hospital medicine at Regions drew industry-wide attention, namely for the program he developed to carve out 96 inpatient mental-health beds to streamline intake and discharge processes. And even though he also directs a fellowship program for HealthPartners Medical Group in Saint Paul, Dr. Siy views his award as a testament to his colleagues.

“When you’re part of a team that you really enjoy, the work becomes easier,” Dr. Siy says. “I feel like it’s an acknowledgement of the way we all work together.” TH

Richard Quinn is a freelance writer based in New Jersey.

SHM has announced the annual Awards of Excellence to hospitalists on the leading edge of the specialty. The honors recognize accomplishments in education, research, clinical care, service, and quality improvement (QI). The praises are as varied as the recipients: They hail from Wisconsin to Pennsylvania, Minnesota to North Carolina.

This year’s awards, presented at the annual President’s Luncheon at HM09 in Chicago, went to:

Award for Excellence in Teaching

Eric Howell, MD, FHM

Johns Hopkins Bayview Medical Center, Baltimore

Dr. Howell is an admitted introvert, so one might assume teaching isn’t the most natural application of his medical talents. But when he became chief resident at Johns Hopkins in 1999, he was forced to lead weekly education sessions. The next year, it was weekly didactic classes as an instructor. Five years later, he made assistant professor; this year he moved up again, to associate professor.

“It’s certainly not my fund of knowledge,” Dr. Howell says. “Students and I enjoy interacting because I enjoy it and I make it fun. What little knowledge I have, I pass on well.”

Dr. Howell’s laid-back style—he asks students to call him Eric, although they rarely do—serves him well in the classroom setting. However, the other hats he wears—as Bayview Medical Center’s hospitalist division director and faculty leader at Helen B. Taussig College—limit his teaching time. In a way, it’s what helped him win the award.

“Because I have many other things to do, [teaching] stays special,” says Dr. Howell, who recently joined SHM’s Board of Directors. “It’s a nice reprieve from some of the other high-pressure things, like treating a sick patient, problem-solving for my hospital, or keeping my hospitalist group running.”

Excellence in Research Award

Samir Shah, MD, MSCE, FHM

Children’s Hospital of Philadelphia

Most medical students don’t set out to be hailed as researchers, and Dr. Shah is no exception. Still, in order to graduate from the Yale University School of Medicine, every student has to complete a research project. The research bug bit Dr. Shah, and he stayed an extra year at Yale to pursue teaching and research interests. Now he’s a leading voice for pediatric hospitalists, an assistant professor of pediatrics and epidemiology at the University of Pennsylvania Medical School of Medicine, and an attending physician at Children’s Hospital of Philadelphia.

“It’s the feeling of making a difference not in the life of one child but the lives of many children,” he says. “To say I fundamentally had an impact on the way we view a disease … that’s a different feeling altogether.”

Dr. Shah’s research has focused on improved management of patients with common childhood infections, particularly pneumonia and meningitis. His research is published regularly, and he serves as editor or co-editor for several journals.

“The goal of our research is to influence policy or clinical practice,” Dr Shah says. “Ideally, both.”

Award for Outstanding Service in HM

Eric Siegal, MD, FHM

University of Wisconsin School of Medicine and Public Health, Madison

Dr. Siegal has been the head of SHM’s Public Policy Committee for nearly four years, and while he jokes that no one else is dumb enough to take on the role, it’s exactly that kind of experience that has earned him the society’s “utility infielder award.”

“It’s gotten harder,” Dr. Siegal says of HM advocacy. “Now that people know what SHM is ... it’s going to get a lot harder, in a good way.”

SHM leaders say Dr. Siegal’s grasp of issues is vital as the federal government weighs the most significant healthcare reform in decades and hospitals struggle to balance costs and efficiency against the push to improve quality of care.

In fact, Dr. Siegal’s reputation within the society is so respected he was co-nominated for this year’s service award by Laura Allendorf, SHM’s senior advisor on advocacy and government affairs. Dr. Siegal currently is a critical-care fellow in Madison, and previously served as regional medical director for Cogent Healthcare.

Award for Clinical Excellence

Jerome Siy, MD, FHM

Regions Hospital, Saint Paul, Minn.

Dr. Siy wants to collaborate on pretty much everything. It doesn’t matter if he’s developing an HM platform that employs nearly 50 hospitalists, teaching at the University of Minnesota Medical School, or creating an interdisciplinary program that pulls together hospitalists, ED physicians, and behavioral health doctors.

“Nothing is successful when one person does all the work,” Dr. Siy says. “It doesn’t help just having department heads in a room. You need the people who are actually working.”

Dr. Siy’s work as chief of hospital medicine at Regions drew industry-wide attention, namely for the program he developed to carve out 96 inpatient mental-health beds to streamline intake and discharge processes. And even though he also directs a fellowship program for HealthPartners Medical Group in Saint Paul, Dr. Siy views his award as a testament to his colleagues.

“When you’re part of a team that you really enjoy, the work becomes easier,” Dr. Siy says. “I feel like it’s an acknowledgement of the way we all work together.” TH

Richard Quinn is a freelance writer based in New Jersey.