MHM

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

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

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

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

Bad Advice: Keeping Up with the Literature

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

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

Better Advice: Keep Up with Literature

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

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

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

Get a Gimmick: Good Advice?

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

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

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

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

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

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

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

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

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

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

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

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

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

Bad Advice: Keeping Up with the Literature

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

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

Better Advice: Keep Up with Literature

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

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

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

Get a Gimmick: Good Advice?

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

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

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

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

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

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

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

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

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

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

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

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

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

Bad Advice: Keeping Up with the Literature

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

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

Better Advice: Keep Up with Literature

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

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

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

Get a Gimmick: Good Advice?

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

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

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

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

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

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

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

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

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

A couple of additions to the list that I started last month, in which I mentioned the problems associated with fixed-duration day shifts, a contractual vacation provision, tenure-based salary increases, poor roles for NPs and PAs, and blinded performance reporting. I think most practices would be better off without those things, and this month I’ll add a few more to the list.

I readily admit that there are some relatively rare situations in which the following things might be a good idea. But most hospitalist practices should think about alternatives.

Extra shifts. I think every hospitalist should have, within reason, a chance to work more or less than others in an HM group. And, of course, compensation should match the amount of work. So those who want to work more than the normal, or contractually required, number of shifts should have at it. But I think it is best to avoid categorizing the work into “normal” shifts and “extra” shifts. Essentially, all shifts should be thought of as “normal.”

What is the problem with having an “extra” shift category? It pretty reliably leads to confusion.

This confusion is easiest to illustrate with an example. Consider Dr. Krause, a hospitalist working in a practice with a seven-on/seven-off schedule. However, the first week in July, she works only six days, but she plans to “pay that back” and more when she works a 10-day stretch two months hence. So far, this sounds easy. By the end of September, Dr. Krause will have worked two extra shifts.

But when another hospitalist in Dr. Krause’s group is out sick in August, several hospitalists in the group rearrange their schedules to fill in. In September, Dr. Krause works the two days that she originally was scheduled to be off and trades away three of the consecutive days she was to work in September.

While it will be clear to Dr. Krause that she will be “even” in the number of shifts worked at the end of September, it probably isn’t clear to anyone else. The person who determines payroll will probably have a really hard time figuring out whether Dr. Krause is to be paid extra for “extra” shifts during any two-week pay period.

The most reliable way to figure out if a doctor worked extra shifts is to add up all worked shifts at the end of the year. But that would mean waiting until the end of the year to compensate the doctor for any extra shifts worked. And most docs would find that really unattractive.

It would be easy enough to just add up the shifts worked every pay period (usually two weeks) and compensate for any above the number expected, but that would then require lowering the salary for any pay period in which the doctor works fewer than the expected number. Although it might not be popular, I see this as the best arrangement. That is, just pay per shift so that there is no need to keep track of whether any particular shift is “normal” or “extra.”

Even if this illustration doesn’t convince you how messy it can be to keep track of extra vs. normal shifts, trust me on this one. It causes lots of problems for lots of physician practices. If your practice is among the few that has a clear-cut system that doesn’t confuse those in payroll, then stick with it.

Shift duration symmetry. Rarely is there a reason to keep every shift the same duration.

Let’s consider a common scenario. A small hospitalist group has a schedule that consists of a 12-hour day shift followed by a 12-hour night shift. As patient volume grows, the day-shift doctor(s) often have to stay after their shift to finish the initial care of new referrals, or the night doctor typically starts their shift with several patients in the ED awaiting admission. So the practice makes a good decision and creates an evening shift, which often is referred to as a “swing shift.” And because all existing shifts are 12 hours, the evening shift will be 12 hours, right?

Not so fast.

Why should the evening shift be the same duration as the day shift? Shouldn’t it be however long is necessary? Practices of no more than about 15 FTEs typically require an evening shift of only about four to six hours. It should start an hour or so before the last day doctor should be finishing work; it should continue until the night doctor has resolved the backlog of patients. As the practice volume grows, it will probably be necessary to lengthen the evening shift until it eventually reaches the same length as other shifts. But there is almost never a real workload or patient-care reason that the shift length needs to be the same duration as other shifts when it is first put into place.

While an evening shift should have a clearly defined start time, it will work best if the end of shift time is left loose and is based on just how busy that night it. For example, it might be reasonable to have the evening doctor accept their last new referral no later than a specified time (10 p.m. is the deadline in my hospitalist group). The swing shift can leave after completing the care of that patient and addressing any other issues that came up during the shift. Some nights, that will mean the evening doctor can leave at 10 p.m.; other nights, it might be 11 p.m. or midnight.

While we’re talking about it, there is no clear reason day and night shifts need to be the same length, either. It is fine to make both 12 hours long, but that isn’t the only reasonable option.

Of course, your compensation formula might influence what can be reasonably done with shift lengths. But if a practice compensates the doctors in a way that requires that all shifts be identical in duration, then the compensation method needs another look. TH

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

A couple of additions to the list that I started last month, in which I mentioned the problems associated with fixed-duration day shifts, a contractual vacation provision, tenure-based salary increases, poor roles for NPs and PAs, and blinded performance reporting. I think most practices would be better off without those things, and this month I’ll add a few more to the list.

I readily admit that there are some relatively rare situations in which the following things might be a good idea. But most hospitalist practices should think about alternatives.

Extra shifts. I think every hospitalist should have, within reason, a chance to work more or less than others in an HM group. And, of course, compensation should match the amount of work. So those who want to work more than the normal, or contractually required, number of shifts should have at it. But I think it is best to avoid categorizing the work into “normal” shifts and “extra” shifts. Essentially, all shifts should be thought of as “normal.”

What is the problem with having an “extra” shift category? It pretty reliably leads to confusion.

This confusion is easiest to illustrate with an example. Consider Dr. Krause, a hospitalist working in a practice with a seven-on/seven-off schedule. However, the first week in July, she works only six days, but she plans to “pay that back” and more when she works a 10-day stretch two months hence. So far, this sounds easy. By the end of September, Dr. Krause will have worked two extra shifts.

But when another hospitalist in Dr. Krause’s group is out sick in August, several hospitalists in the group rearrange their schedules to fill in. In September, Dr. Krause works the two days that she originally was scheduled to be off and trades away three of the consecutive days she was to work in September.

While it will be clear to Dr. Krause that she will be “even” in the number of shifts worked at the end of September, it probably isn’t clear to anyone else. The person who determines payroll will probably have a really hard time figuring out whether Dr. Krause is to be paid extra for “extra” shifts during any two-week pay period.

The most reliable way to figure out if a doctor worked extra shifts is to add up all worked shifts at the end of the year. But that would mean waiting until the end of the year to compensate the doctor for any extra shifts worked. And most docs would find that really unattractive.

It would be easy enough to just add up the shifts worked every pay period (usually two weeks) and compensate for any above the number expected, but that would then require lowering the salary for any pay period in which the doctor works fewer than the expected number. Although it might not be popular, I see this as the best arrangement. That is, just pay per shift so that there is no need to keep track of whether any particular shift is “normal” or “extra.”

Even if this illustration doesn’t convince you how messy it can be to keep track of extra vs. normal shifts, trust me on this one. It causes lots of problems for lots of physician practices. If your practice is among the few that has a clear-cut system that doesn’t confuse those in payroll, then stick with it.

Shift duration symmetry. Rarely is there a reason to keep every shift the same duration.

Let’s consider a common scenario. A small hospitalist group has a schedule that consists of a 12-hour day shift followed by a 12-hour night shift. As patient volume grows, the day-shift doctor(s) often have to stay after their shift to finish the initial care of new referrals, or the night doctor typically starts their shift with several patients in the ED awaiting admission. So the practice makes a good decision and creates an evening shift, which often is referred to as a “swing shift.” And because all existing shifts are 12 hours, the evening shift will be 12 hours, right?

Not so fast.

Why should the evening shift be the same duration as the day shift? Shouldn’t it be however long is necessary? Practices of no more than about 15 FTEs typically require an evening shift of only about four to six hours. It should start an hour or so before the last day doctor should be finishing work; it should continue until the night doctor has resolved the backlog of patients. As the practice volume grows, it will probably be necessary to lengthen the evening shift until it eventually reaches the same length as other shifts. But there is almost never a real workload or patient-care reason that the shift length needs to be the same duration as other shifts when it is first put into place.

While an evening shift should have a clearly defined start time, it will work best if the end of shift time is left loose and is based on just how busy that night it. For example, it might be reasonable to have the evening doctor accept their last new referral no later than a specified time (10 p.m. is the deadline in my hospitalist group). The swing shift can leave after completing the care of that patient and addressing any other issues that came up during the shift. Some nights, that will mean the evening doctor can leave at 10 p.m.; other nights, it might be 11 p.m. or midnight.

While we’re talking about it, there is no clear reason day and night shifts need to be the same length, either. It is fine to make both 12 hours long, but that isn’t the only reasonable option.

Of course, your compensation formula might influence what can be reasonably done with shift lengths. But if a practice compensates the doctors in a way that requires that all shifts be identical in duration, then the compensation method needs another look. TH

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

A couple of additions to the list that I started last month, in which I mentioned the problems associated with fixed-duration day shifts, a contractual vacation provision, tenure-based salary increases, poor roles for NPs and PAs, and blinded performance reporting. I think most practices would be better off without those things, and this month I’ll add a few more to the list.

I readily admit that there are some relatively rare situations in which the following things might be a good idea. But most hospitalist practices should think about alternatives.

Extra shifts. I think every hospitalist should have, within reason, a chance to work more or less than others in an HM group. And, of course, compensation should match the amount of work. So those who want to work more than the normal, or contractually required, number of shifts should have at it. But I think it is best to avoid categorizing the work into “normal” shifts and “extra” shifts. Essentially, all shifts should be thought of as “normal.”

What is the problem with having an “extra” shift category? It pretty reliably leads to confusion.

This confusion is easiest to illustrate with an example. Consider Dr. Krause, a hospitalist working in a practice with a seven-on/seven-off schedule. However, the first week in July, she works only six days, but she plans to “pay that back” and more when she works a 10-day stretch two months hence. So far, this sounds easy. By the end of September, Dr. Krause will have worked two extra shifts.

But when another hospitalist in Dr. Krause’s group is out sick in August, several hospitalists in the group rearrange their schedules to fill in. In September, Dr. Krause works the two days that she originally was scheduled to be off and trades away three of the consecutive days she was to work in September.

While it will be clear to Dr. Krause that she will be “even” in the number of shifts worked at the end of September, it probably isn’t clear to anyone else. The person who determines payroll will probably have a really hard time figuring out whether Dr. Krause is to be paid extra for “extra” shifts during any two-week pay period.

The most reliable way to figure out if a doctor worked extra shifts is to add up all worked shifts at the end of the year. But that would mean waiting until the end of the year to compensate the doctor for any extra shifts worked. And most docs would find that really unattractive.

It would be easy enough to just add up the shifts worked every pay period (usually two weeks) and compensate for any above the number expected, but that would then require lowering the salary for any pay period in which the doctor works fewer than the expected number. Although it might not be popular, I see this as the best arrangement. That is, just pay per shift so that there is no need to keep track of whether any particular shift is “normal” or “extra.”

Even if this illustration doesn’t convince you how messy it can be to keep track of extra vs. normal shifts, trust me on this one. It causes lots of problems for lots of physician practices. If your practice is among the few that has a clear-cut system that doesn’t confuse those in payroll, then stick with it.

Shift duration symmetry. Rarely is there a reason to keep every shift the same duration.

Let’s consider a common scenario. A small hospitalist group has a schedule that consists of a 12-hour day shift followed by a 12-hour night shift. As patient volume grows, the day-shift doctor(s) often have to stay after their shift to finish the initial care of new referrals, or the night doctor typically starts their shift with several patients in the ED awaiting admission. So the practice makes a good decision and creates an evening shift, which often is referred to as a “swing shift.” And because all existing shifts are 12 hours, the evening shift will be 12 hours, right?

Not so fast.

Why should the evening shift be the same duration as the day shift? Shouldn’t it be however long is necessary? Practices of no more than about 15 FTEs typically require an evening shift of only about four to six hours. It should start an hour or so before the last day doctor should be finishing work; it should continue until the night doctor has resolved the backlog of patients. As the practice volume grows, it will probably be necessary to lengthen the evening shift until it eventually reaches the same length as other shifts. But there is almost never a real workload or patient-care reason that the shift length needs to be the same duration as other shifts when it is first put into place.

While an evening shift should have a clearly defined start time, it will work best if the end of shift time is left loose and is based on just how busy that night it. For example, it might be reasonable to have the evening doctor accept their last new referral no later than a specified time (10 p.m. is the deadline in my hospitalist group). The swing shift can leave after completing the care of that patient and addressing any other issues that came up during the shift. Some nights, that will mean the evening doctor can leave at 10 p.m.; other nights, it might be 11 p.m. or midnight.

While we’re talking about it, there is no clear reason day and night shifts need to be the same length, either. It is fine to make both 12 hours long, but that isn’t the only reasonable option.

Of course, your compensation formula might influence what can be reasonably done with shift lengths. But if a practice compensates the doctors in a way that requires that all shifts be identical in duration, then the compensation method needs another look. TH

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

I’m often asked about the attributes associated with high-functioning practices, so I thought I’d offer a list of them in this column. I’ve written entire columns about some of them in prior issues of The Hospitalist, so I will provide only brief commentary about each of them here.

I think this list can serve as a valuable frame of reference for any hospitalist practice, though it is geared more toward nonacademic settings. It is based on my own career as a hospitalist, which spans more than 20 years, and 15 years’ work as a consultant with nearly 300 institutions around the country. While I think my experience has given me a valuable perspective, others might reasonably omit some attributes listed here or add others.

I believe the single most important measure of a practice is excellent outcomes for its patients. That said, all of the attributes I describe here have more to do with excellent operational, or business, performance. It is possible for a practice to have all of these attributes and still provide disappointing clinical quality for its patients, but that seems really unlikely to me. And even a practice that provides superior clinical care probably won’t be able to do so for long without high-functioning business operations.

I think each of these attributes might be a cause of a practice’s excellent performance, but it is possible that some are a result of it. They are listed in no particular order.

A culture of practice ownership. The most important attribute associated with a high-functioning practice is that the providers in the group maintain a mindset of practice ownership. Even if you are employees of a hospital or other organization, you should think of yourselves as owners of the practice’s performance. When problems arise, you shouldn’t simply assume it is up to the practice leader alone, or an administrator outside of the practice to solve it. Instead, each doctor should always be thinking about how to improve the practice and taking action to make it happen. For more, see “Foster Ownership Culture” in the August 2008 issue, or visit my website and take a quiz (http://nelsonflores.com/html/quiz.html) to assess your ownership culture.

An effective group leader. All groups need a leader who takes the role seriously and doesn’t just view the job description as making the work schedule and attending more meetings than the other hospitalists. (Unfortunately, my experience is that this is precisely what a lot of leaders think.) Of the many markers that effective leaders display, one that seems pretty reliable to me is whether the group has routinely scheduled meetings, with an agenda provided in advance and minutes circulated a few days later. I wrote about effective group leaders in a June 2008 column titled “Follow the Money.”

Autonomy in making decisions. Even when you are an employee of a larger entity, the practice should be structured so that hospitalists have as much autonomy in decision-making as possible. For example, you should always be able to adjust the group’s work schedule (e.g. when shifts start and stop). You also should have a lot of say about your staffing and workload. The latter typically requires that the group is connected to the financial consequences of its choices, which usually means a compensation system based, to a significant degree, on productivity.

While still common for hospitalists, when the largest salary component is fixed, it will always follow that someone outside the group (e.g. an administrator at the hospital) will end up deciding how hard you will have to work to justify the promised salary. And the hospitalists will almost always find fault with that person’s decision—a recipe for constant frustration that inhibits the development of an ownership culture, among other things.

Each doctor sees the job as more than just providing care to patients. In addition to providing quality care for your patients, each hospitalist in the group must work to improve the performance of the hospital. This means work on clinical protocols, medical staff functions (e.g. credentials committee), documentation and coding for both CPT and DRG billing, etc.

Strong social connections. Every high-performing practice I’ve worked with is notable for the social connections between the hospitalists themselves, as well as between hospitalists and other physicians, nursing staff, and administrators. This shouldn’t be taken lightly. Social connections matter—a lot. And while the hospitalists in most groups feel reasonably connected with one another, too often they feel isolated from the other doctors and administrators at the hospital. I wrote some more thoughts about this in a June 2010 column, “Square Peg, Square Hole.”

Hospitalists actively involved in recruiting for their practice. The hospitalists themselves—at a minimum, the group leader—should be very involved in recruiting new members for the group. Professional recruiters are very valuable but can be a lot more effective if the hospitalists themselves participate in the process. The group will land better candidates that way. For more, see “We’re Hiring,” from July 2008.

Hospitalists know data about their performance. Too many practices fail to provide routine data about each provider’s clinical and financial performance. Make sure your group isn’t in this category. Develop a routine report of key metrics for your practice. Usually it is fine, and best, to provide to the whole group unblinded performance data about each individual hospitalist. For more information, check out “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” on the SHM website.

Don’t rely solely on consensus-based decision-making. Relying on consensus is reasonable for most decisions, if a group has about eight to 10 members. Larger groups need to decide how they’ll make decisions if consensus can’t be reached easily. And they need to have the discipline to stick to their agreed upon process, usually a vote. For more on this subject, see “Play by the Rules” in the December 2007 issue. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and 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.

I’m often asked about the attributes associated with high-functioning practices, so I thought I’d offer a list of them in this column. I’ve written entire columns about some of them in prior issues of The Hospitalist, so I will provide only brief commentary about each of them here.

I think this list can serve as a valuable frame of reference for any hospitalist practice, though it is geared more toward nonacademic settings. It is based on my own career as a hospitalist, which spans more than 20 years, and 15 years’ work as a consultant with nearly 300 institutions around the country. While I think my experience has given me a valuable perspective, others might reasonably omit some attributes listed here or add others.

I believe the single most important measure of a practice is excellent outcomes for its patients. That said, all of the attributes I describe here have more to do with excellent operational, or business, performance. It is possible for a practice to have all of these attributes and still provide disappointing clinical quality for its patients, but that seems really unlikely to me. And even a practice that provides superior clinical care probably won’t be able to do so for long without high-functioning business operations.

I think each of these attributes might be a cause of a practice’s excellent performance, but it is possible that some are a result of it. They are listed in no particular order.

A culture of practice ownership. The most important attribute associated with a high-functioning practice is that the providers in the group maintain a mindset of practice ownership. Even if you are employees of a hospital or other organization, you should think of yourselves as owners of the practice’s performance. When problems arise, you shouldn’t simply assume it is up to the practice leader alone, or an administrator outside of the practice to solve it. Instead, each doctor should always be thinking about how to improve the practice and taking action to make it happen. For more, see “Foster Ownership Culture” in the August 2008 issue, or visit my website and take a quiz (http://nelsonflores.com/html/quiz.html) to assess your ownership culture.

An effective group leader. All groups need a leader who takes the role seriously and doesn’t just view the job description as making the work schedule and attending more meetings than the other hospitalists. (Unfortunately, my experience is that this is precisely what a lot of leaders think.) Of the many markers that effective leaders display, one that seems pretty reliable to me is whether the group has routinely scheduled meetings, with an agenda provided in advance and minutes circulated a few days later. I wrote about effective group leaders in a June 2008 column titled “Follow the Money.”

Autonomy in making decisions. Even when you are an employee of a larger entity, the practice should be structured so that hospitalists have as much autonomy in decision-making as possible. For example, you should always be able to adjust the group’s work schedule (e.g. when shifts start and stop). You also should have a lot of say about your staffing and workload. The latter typically requires that the group is connected to the financial consequences of its choices, which usually means a compensation system based, to a significant degree, on productivity.

While still common for hospitalists, when the largest salary component is fixed, it will always follow that someone outside the group (e.g. an administrator at the hospital) will end up deciding how hard you will have to work to justify the promised salary. And the hospitalists will almost always find fault with that person’s decision—a recipe for constant frustration that inhibits the development of an ownership culture, among other things.

Each doctor sees the job as more than just providing care to patients. In addition to providing quality care for your patients, each hospitalist in the group must work to improve the performance of the hospital. This means work on clinical protocols, medical staff functions (e.g. credentials committee), documentation and coding for both CPT and DRG billing, etc.

Strong social connections. Every high-performing practice I’ve worked with is notable for the social connections between the hospitalists themselves, as well as between hospitalists and other physicians, nursing staff, and administrators. This shouldn’t be taken lightly. Social connections matter—a lot. And while the hospitalists in most groups feel reasonably connected with one another, too often they feel isolated from the other doctors and administrators at the hospital. I wrote some more thoughts about this in a June 2010 column, “Square Peg, Square Hole.”

Hospitalists actively involved in recruiting for their practice. The hospitalists themselves—at a minimum, the group leader—should be very involved in recruiting new members for the group. Professional recruiters are very valuable but can be a lot more effective if the hospitalists themselves participate in the process. The group will land better candidates that way. For more, see “We’re Hiring,” from July 2008.

Hospitalists know data about their performance. Too many practices fail to provide routine data about each provider’s clinical and financial performance. Make sure your group isn’t in this category. Develop a routine report of key metrics for your practice. Usually it is fine, and best, to provide to the whole group unblinded performance data about each individual hospitalist. For more information, check out “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” on the SHM website.

Don’t rely solely on consensus-based decision-making. Relying on consensus is reasonable for most decisions, if a group has about eight to 10 members. Larger groups need to decide how they’ll make decisions if consensus can’t be reached easily. And they need to have the discipline to stick to their agreed upon process, usually a vote. For more on this subject, see “Play by the Rules” in the December 2007 issue. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and 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.

I’m often asked about the attributes associated with high-functioning practices, so I thought I’d offer a list of them in this column. I’ve written entire columns about some of them in prior issues of The Hospitalist, so I will provide only brief commentary about each of them here.

I think this list can serve as a valuable frame of reference for any hospitalist practice, though it is geared more toward nonacademic settings. It is based on my own career as a hospitalist, which spans more than 20 years, and 15 years’ work as a consultant with nearly 300 institutions around the country. While I think my experience has given me a valuable perspective, others might reasonably omit some attributes listed here or add others.

I believe the single most important measure of a practice is excellent outcomes for its patients. That said, all of the attributes I describe here have more to do with excellent operational, or business, performance. It is possible for a practice to have all of these attributes and still provide disappointing clinical quality for its patients, but that seems really unlikely to me. And even a practice that provides superior clinical care probably won’t be able to do so for long without high-functioning business operations.

I think each of these attributes might be a cause of a practice’s excellent performance, but it is possible that some are a result of it. They are listed in no particular order.

A culture of practice ownership. The most important attribute associated with a high-functioning practice is that the providers in the group maintain a mindset of practice ownership. Even if you are employees of a hospital or other organization, you should think of yourselves as owners of the practice’s performance. When problems arise, you shouldn’t simply assume it is up to the practice leader alone, or an administrator outside of the practice to solve it. Instead, each doctor should always be thinking about how to improve the practice and taking action to make it happen. For more, see “Foster Ownership Culture” in the August 2008 issue, or visit my website and take a quiz (http://nelsonflores.com/html/quiz.html) to assess your ownership culture.

An effective group leader. All groups need a leader who takes the role seriously and doesn’t just view the job description as making the work schedule and attending more meetings than the other hospitalists. (Unfortunately, my experience is that this is precisely what a lot of leaders think.) Of the many markers that effective leaders display, one that seems pretty reliable to me is whether the group has routinely scheduled meetings, with an agenda provided in advance and minutes circulated a few days later. I wrote about effective group leaders in a June 2008 column titled “Follow the Money.”

Autonomy in making decisions. Even when you are an employee of a larger entity, the practice should be structured so that hospitalists have as much autonomy in decision-making as possible. For example, you should always be able to adjust the group’s work schedule (e.g. when shifts start and stop). You also should have a lot of say about your staffing and workload. The latter typically requires that the group is connected to the financial consequences of its choices, which usually means a compensation system based, to a significant degree, on productivity.

While still common for hospitalists, when the largest salary component is fixed, it will always follow that someone outside the group (e.g. an administrator at the hospital) will end up deciding how hard you will have to work to justify the promised salary. And the hospitalists will almost always find fault with that person’s decision—a recipe for constant frustration that inhibits the development of an ownership culture, among other things.

Each doctor sees the job as more than just providing care to patients. In addition to providing quality care for your patients, each hospitalist in the group must work to improve the performance of the hospital. This means work on clinical protocols, medical staff functions (e.g. credentials committee), documentation and coding for both CPT and DRG billing, etc.

Strong social connections. Every high-performing practice I’ve worked with is notable for the social connections between the hospitalists themselves, as well as between hospitalists and other physicians, nursing staff, and administrators. This shouldn’t be taken lightly. Social connections matter—a lot. And while the hospitalists in most groups feel reasonably connected with one another, too often they feel isolated from the other doctors and administrators at the hospital. I wrote some more thoughts about this in a June 2010 column, “Square Peg, Square Hole.”

Hospitalists actively involved in recruiting for their practice. The hospitalists themselves—at a minimum, the group leader—should be very involved in recruiting new members for the group. Professional recruiters are very valuable but can be a lot more effective if the hospitalists themselves participate in the process. The group will land better candidates that way. For more, see “We’re Hiring,” from July 2008.

Hospitalists know data about their performance. Too many practices fail to provide routine data about each provider’s clinical and financial performance. Make sure your group isn’t in this category. Develop a routine report of key metrics for your practice. Usually it is fine, and best, to provide to the whole group unblinded performance data about each individual hospitalist. For more information, check out “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” on the SHM website.

Don’t rely solely on consensus-based decision-making. Relying on consensus is reasonable for most decisions, if a group has about eight to 10 members. Larger groups need to decide how they’ll make decisions if consensus can’t be reached easily. And they need to have the discipline to stick to their agreed upon process, usually a vote. For more on this subject, see “Play by the Rules” in the December 2007 issue. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and 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.

I like to ask laypeople what they think “hospitalist” means. For years, I was confident that they had never heard the term, but now my question is more often met with an accurate response.

A hotel desk clerk in 1998 actually made one of the cleverest guesses I’ve ever heard. For the whole day, she and her colleagues had in front of them a sign that read “Hospitalist Meeting in the Ballroom,” which got them talking about what in the world a hospitalist is. Seeing from my badge that I was attending that meeting, she asked me what the term meant, but she first gamely provided her best guess: “Someone who makes lists of hospitals.”

There seems to be no end to the number of healthcare-related nouns and verbs to which someone attaches the suffix “ist.” Some days I request so many consults that I’m just a “referralist” (one who refers patients; surely this is a term we can do without). But don’t let the headline of this column confuse you: I really am addressing the lists used to determine which doctor to refer patients to.

Hospitalist Referrals

The first of two common referral lists for hospitalists is a directory of primary-care physicians (PCPs) and clinics, as well as some other providers that refer patients to the hospitalist. Nearly all hospitalist groups maintain such a list, and they might apply a variety of terms such as “subscriber” (which refers to hospitalists) and “nonsubscriber” physicians.

Because most HM groups care for patients who come from all or nearly all of the PCPs in an area, it is often simpler to just create a short list of those providers who don’t refer to the hospitalists. In many hospitals, there are just four or five providers on that list. ED providers are the ones who most often access this list. When visiting other hospitals, I often see a paper copy of the list taped up at the provider workstations in the ED.

Consult Who?

The other, and much less common, type of referral list governs which doctors the hospitalists are to consult. There are two strategies that come up when thinking about this kind of list.

Do what the ED doctors do. ED physicians typically are constrained by the list of on-call physicians for each specialty, and are to always consult that doctor rather than another. For example, the ED doctor is required to consult Dr. Taylor for any patient in need of a general surgeon and doesn’t have a prior relationship with one. Tomorrow, the ED doctor is required to consult Dr. Simon. Dr. Taylor and Dr. Simon are to be contacted because they are the ones on call for the ED those days. Even if the ED doctor would rather consult Dr. Simon today (maybe she is more able, affable, and available than Dr. Taylor), that isn’t an option, because it is Dr. Taylor’s name on the ED on-call roster today.

Each PCP creates a referral list for hospitalists to follow. New hospitalist practices often agree to follow the consulting patterns of each referring PCP. This can increase PCP acceptance of the HM model, and after all, the GI doctor consulted by the hospitalist during the few days in the hospital is the same one who will be working with the PCP when the patient has outpatient issues requiring GI specialty care. This usually means that the hospitalist carries a list of each PCP, and which GI doctor, orthopedist, etc., that particular PCP likes to consult. When the hospitalist needs an ortho consult, she first verifies the PCP this patient sees, then pulls out the list to see the orthopedist(s) that PCP prefers.

In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.

Practical Considerations

Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.

The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.

And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. TH

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

I like to ask laypeople what they think “hospitalist” means. For years, I was confident that they had never heard the term, but now my question is more often met with an accurate response.

A hotel desk clerk in 1998 actually made one of the cleverest guesses I’ve ever heard. For the whole day, she and her colleagues had in front of them a sign that read “Hospitalist Meeting in the Ballroom,” which got them talking about what in the world a hospitalist is. Seeing from my badge that I was attending that meeting, she asked me what the term meant, but she first gamely provided her best guess: “Someone who makes lists of hospitals.”

There seems to be no end to the number of healthcare-related nouns and verbs to which someone attaches the suffix “ist.” Some days I request so many consults that I’m just a “referralist” (one who refers patients; surely this is a term we can do without). But don’t let the headline of this column confuse you: I really am addressing the lists used to determine which doctor to refer patients to.

Hospitalist Referrals

The first of two common referral lists for hospitalists is a directory of primary-care physicians (PCPs) and clinics, as well as some other providers that refer patients to the hospitalist. Nearly all hospitalist groups maintain such a list, and they might apply a variety of terms such as “subscriber” (which refers to hospitalists) and “nonsubscriber” physicians.

Because most HM groups care for patients who come from all or nearly all of the PCPs in an area, it is often simpler to just create a short list of those providers who don’t refer to the hospitalists. In many hospitals, there are just four or five providers on that list. ED providers are the ones who most often access this list. When visiting other hospitals, I often see a paper copy of the list taped up at the provider workstations in the ED.

Consult Who?

The other, and much less common, type of referral list governs which doctors the hospitalists are to consult. There are two strategies that come up when thinking about this kind of list.

Do what the ED doctors do. ED physicians typically are constrained by the list of on-call physicians for each specialty, and are to always consult that doctor rather than another. For example, the ED doctor is required to consult Dr. Taylor for any patient in need of a general surgeon and doesn’t have a prior relationship with one. Tomorrow, the ED doctor is required to consult Dr. Simon. Dr. Taylor and Dr. Simon are to be contacted because they are the ones on call for the ED those days. Even if the ED doctor would rather consult Dr. Simon today (maybe she is more able, affable, and available than Dr. Taylor), that isn’t an option, because it is Dr. Taylor’s name on the ED on-call roster today.

Each PCP creates a referral list for hospitalists to follow. New hospitalist practices often agree to follow the consulting patterns of each referring PCP. This can increase PCP acceptance of the HM model, and after all, the GI doctor consulted by the hospitalist during the few days in the hospital is the same one who will be working with the PCP when the patient has outpatient issues requiring GI specialty care. This usually means that the hospitalist carries a list of each PCP, and which GI doctor, orthopedist, etc., that particular PCP likes to consult. When the hospitalist needs an ortho consult, she first verifies the PCP this patient sees, then pulls out the list to see the orthopedist(s) that PCP prefers.

In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.

Practical Considerations

Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.

The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.

And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. TH

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

I like to ask laypeople what they think “hospitalist” means. For years, I was confident that they had never heard the term, but now my question is more often met with an accurate response.

A hotel desk clerk in 1998 actually made one of the cleverest guesses I’ve ever heard. For the whole day, she and her colleagues had in front of them a sign that read “Hospitalist Meeting in the Ballroom,” which got them talking about what in the world a hospitalist is. Seeing from my badge that I was attending that meeting, she asked me what the term meant, but she first gamely provided her best guess: “Someone who makes lists of hospitals.”

There seems to be no end to the number of healthcare-related nouns and verbs to which someone attaches the suffix “ist.” Some days I request so many consults that I’m just a “referralist” (one who refers patients; surely this is a term we can do without). But don’t let the headline of this column confuse you: I really am addressing the lists used to determine which doctor to refer patients to.

Hospitalist Referrals

The first of two common referral lists for hospitalists is a directory of primary-care physicians (PCPs) and clinics, as well as some other providers that refer patients to the hospitalist. Nearly all hospitalist groups maintain such a list, and they might apply a variety of terms such as “subscriber” (which refers to hospitalists) and “nonsubscriber” physicians.

Because most HM groups care for patients who come from all or nearly all of the PCPs in an area, it is often simpler to just create a short list of those providers who don’t refer to the hospitalists. In many hospitals, there are just four or five providers on that list. ED providers are the ones who most often access this list. When visiting other hospitals, I often see a paper copy of the list taped up at the provider workstations in the ED.

Consult Who?

The other, and much less common, type of referral list governs which doctors the hospitalists are to consult. There are two strategies that come up when thinking about this kind of list.

Do what the ED doctors do. ED physicians typically are constrained by the list of on-call physicians for each specialty, and are to always consult that doctor rather than another. For example, the ED doctor is required to consult Dr. Taylor for any patient in need of a general surgeon and doesn’t have a prior relationship with one. Tomorrow, the ED doctor is required to consult Dr. Simon. Dr. Taylor and Dr. Simon are to be contacted because they are the ones on call for the ED those days. Even if the ED doctor would rather consult Dr. Simon today (maybe she is more able, affable, and available than Dr. Taylor), that isn’t an option, because it is Dr. Taylor’s name on the ED on-call roster today.

Each PCP creates a referral list for hospitalists to follow. New hospitalist practices often agree to follow the consulting patterns of each referring PCP. This can increase PCP acceptance of the HM model, and after all, the GI doctor consulted by the hospitalist during the few days in the hospital is the same one who will be working with the PCP when the patient has outpatient issues requiring GI specialty care. This usually means that the hospitalist carries a list of each PCP, and which GI doctor, orthopedist, etc., that particular PCP likes to consult. When the hospitalist needs an ortho consult, she first verifies the PCP this patient sees, then pulls out the list to see the orthopedist(s) that PCP prefers.

In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.

Practical Considerations

Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.

The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.

And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. TH

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

Unpredictable workloads and frequent interruptions are the things I regard as the most stressful components of work as a hospitalist. Your list might be very different, but I bet unpredictable workloads ranks at least in the top five of every hospitalist’s list.

I’ve discussed interruptions previously (see “Really, It’s Switch-Tasking,” p. 68, November 2008; “Technological Advance or Workplace Setback?” p. 69, December 2008), but this month and next will turn to unpredictable workloads. In other words, what are the strategies available to a hospitalist practice to provide surge capacity in response to such unpredictable increases in patient volume as an uptick in census or daily admissions 50% to 100% above normal? I’ll leave to others the topic of how hospitals respond to such disasters as terrorist attacks, earthquakes, etc.

The Bottom Line

Sadly, there is no magic bullet for the “surge” problem, and no way to protect on-duty hospitalists from the need to work harder when it gets busy. But we needn’t feel too sorry for ourselves; doctors in most other specialties who practice in the hospital face the same problem and tend to rely heavily on simply working harder and longer when it is unusually busy. Sometimes they couple the “work harder” mantra with other strategies, such as calling another doctor in to help.

Hospitalists have a duty to ensure high patient volume doesn’t lead to deterioration in the quality of patient care, but occasionally working longer days than average probably poses a low risk, and might be less risky than the additional handoffs usually associated with having a doctor on “jeopardy” to be called in when it’s busy. Routinely or frequently working unreasonably long days is another story.

The trick for HM programs is to build some surge capacity into the routine daily staffing 1) without exceeding a reasonable budget, while 2) ensuring that the hospitalists don’t simply become accustomed to light workloads as the only reasonable norm, which could lead to them becoming unwilling to accept higher, but still reasonable, workloads when needed. (More on these issues later.) First, I’ll go through what I see as the pros and cons of several approaches to addressing surges in patient volume. All are in use with variable frequency around the country.

“Jeopardy” System

In its most common form, a jeopardy system has an unscheduled doctor each day who must remain available on short notice by pager. When patient volume surges, the unscheduled doctor is paged to come in and help. In most cases, this doctor focuses primarily—or exclusively—on admitting patients for a few hours. So it is most common for this doctor to be called in late in the afternoon or early in the evening. The jeopardy doctor usually turns over all admitted patients to another hospitalist in the group for all subsequent care. In addition to providing surge capacity, the jeopardy doctor almost always is used to cover unexpected absences of scheduled doctors, including illness-related absences.

Sometimes this doctor is paid extra for each day or week spent being “available” on jeopardy duty (not to be confused with jury duty, though it can be equally difficult to get exempted from). Then again, it is not uncommon to have jeopardy duty included in base compensation. However, once a jeopardy doctor is actually called in to work, most practices pay additional compensation, often based on an hourly rate that usually is higher than the average compensation generated per hour for nonjeopardy work.

There are a number of reasonable ways to compensate the jeopardy doctor. You probably can get some good ideas by talking with others in your hospital who function in a similar capacity, such as cath-lab technicians who get called in on nights and weekends.

No definitive data are available to show how common the jeopardy system is, but my experience is that 30% to 50% of HM groups use some form of it. Its popularity is proof that it is a reasonable system, but I’m not convinced. I think it is in use by a lot of groups not because it is an optimal way to ensure surge capacity, but because it is easy to conceptualize and put in place, and because many hospitalists came from residency programs in which the system was standard.

The gaps between theoretical and realized benefits become evident once a practice implements a jeopardy system. For example, it might be really busy today, but Dr. Stravinsky doesn’t call in Dr. Copeland, who is on jeopardy, because next week their roles will be reversed and Dr. Stravinsky sure hopes he won’t be called in. No one wants to be the weak doctor who calls in the jeopardy doctor and spoils what was otherwise a day off.

I’ve worked with a lot of practices who say they have a jeopardy system in place, but when I ask for the last time the jeopardy doctor was called in, they say it has been more than a year, or in some cases never. So even if the policy manual says they have a jeopardy system, the doctors never activate it, so it provides no benefit.

Practices that do utilize the jeopardy doctor have their own problems, such as assigning that doctor’s admissions the next day. The jeopardy doctor might provide some relief today, but they essentially just delay the work of having to get to know all of those new patients until the morning, when everyone is very busy with rounds. So while there might be significant benefit in activating the jeopardy system today, it could just delay the problem of high workload until the next morning, which isn’t much of a net benefit for the practice.

A small number of practices call in the jeopardy doctor frequently, and sometimes have that doctor continue to round on admitted patients for the next few days. This usage might get the most value out of the system, but the practice should consider if it is more cost-effective, and less stressful for the doctors, if the system were reversed. For example, instead of having the doctor on jeopardy and called in as necessary, the doctor would report to work and be given the day off or let go early when it isn’t busy.

Despite my reservations, if you are convinced the jeopardy system is valuable and cost-effective, keep it in place. However, if your group is thinking about options to handle surge capacity, don’t be too quick to adopt a jeopardy system. It usually falls far short of a perfect solution.

Patient Volume Cap

Another way to address the problem of unpredictable increases in patient volume is to establish a patient volume (e.g., total census) cap for the whole hospitalist practice. Like the jeopardy system, this is an appealingly uncomplicated idea, and hospitalists who have finished residency within the last few years all worked with a cap.

Except for the rarest of exceptions, this is a poor idea and should be avoided if at all possible. I’ll leave for another time a discussion of all the political and financial costs of a cap system, but trust me on this one. It is best to avoid a cap.

Stay Tuned …

Next month, I’ll examine other strategies to provide surge capacity. I think they’re more valuable than the two I’ve mentioned here, but I need to warn you that they aren’t perfect and are more complicated to operationalize. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelson flores.com). He is course co-director and 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.

Unpredictable workloads and frequent interruptions are the things I regard as the most stressful components of work as a hospitalist. Your list might be very different, but I bet unpredictable workloads ranks at least in the top five of every hospitalist’s list.

I’ve discussed interruptions previously (see “Really, It’s Switch-Tasking,” p. 68, November 2008; “Technological Advance or Workplace Setback?” p. 69, December 2008), but this month and next will turn to unpredictable workloads. In other words, what are the strategies available to a hospitalist practice to provide surge capacity in response to such unpredictable increases in patient volume as an uptick in census or daily admissions 50% to 100% above normal? I’ll leave to others the topic of how hospitals respond to such disasters as terrorist attacks, earthquakes, etc.

The Bottom Line

Sadly, there is no magic bullet for the “surge” problem, and no way to protect on-duty hospitalists from the need to work harder when it gets busy. But we needn’t feel too sorry for ourselves; doctors in most other specialties who practice in the hospital face the same problem and tend to rely heavily on simply working harder and longer when it is unusually busy. Sometimes they couple the “work harder” mantra with other strategies, such as calling another doctor in to help.

Hospitalists have a duty to ensure high patient volume doesn’t lead to deterioration in the quality of patient care, but occasionally working longer days than average probably poses a low risk, and might be less risky than the additional handoffs usually associated with having a doctor on “jeopardy” to be called in when it’s busy. Routinely or frequently working unreasonably long days is another story.

The trick for HM programs is to build some surge capacity into the routine daily staffing 1) without exceeding a reasonable budget, while 2) ensuring that the hospitalists don’t simply become accustomed to light workloads as the only reasonable norm, which could lead to them becoming unwilling to accept higher, but still reasonable, workloads when needed. (More on these issues later.) First, I’ll go through what I see as the pros and cons of several approaches to addressing surges in patient volume. All are in use with variable frequency around the country.

“Jeopardy” System

In its most common form, a jeopardy system has an unscheduled doctor each day who must remain available on short notice by pager. When patient volume surges, the unscheduled doctor is paged to come in and help. In most cases, this doctor focuses primarily—or exclusively—on admitting patients for a few hours. So it is most common for this doctor to be called in late in the afternoon or early in the evening. The jeopardy doctor usually turns over all admitted patients to another hospitalist in the group for all subsequent care. In addition to providing surge capacity, the jeopardy doctor almost always is used to cover unexpected absences of scheduled doctors, including illness-related absences.

Sometimes this doctor is paid extra for each day or week spent being “available” on jeopardy duty (not to be confused with jury duty, though it can be equally difficult to get exempted from). Then again, it is not uncommon to have jeopardy duty included in base compensation. However, once a jeopardy doctor is actually called in to work, most practices pay additional compensation, often based on an hourly rate that usually is higher than the average compensation generated per hour for nonjeopardy work.

There are a number of reasonable ways to compensate the jeopardy doctor. You probably can get some good ideas by talking with others in your hospital who function in a similar capacity, such as cath-lab technicians who get called in on nights and weekends.

No definitive data are available to show how common the jeopardy system is, but my experience is that 30% to 50% of HM groups use some form of it. Its popularity is proof that it is a reasonable system, but I’m not convinced. I think it is in use by a lot of groups not because it is an optimal way to ensure surge capacity, but because it is easy to conceptualize and put in place, and because many hospitalists came from residency programs in which the system was standard.

The gaps between theoretical and realized benefits become evident once a practice implements a jeopardy system. For example, it might be really busy today, but Dr. Stravinsky doesn’t call in Dr. Copeland, who is on jeopardy, because next week their roles will be reversed and Dr. Stravinsky sure hopes he won’t be called in. No one wants to be the weak doctor who calls in the jeopardy doctor and spoils what was otherwise a day off.

I’ve worked with a lot of practices who say they have a jeopardy system in place, but when I ask for the last time the jeopardy doctor was called in, they say it has been more than a year, or in some cases never. So even if the policy manual says they have a jeopardy system, the doctors never activate it, so it provides no benefit.

Practices that do utilize the jeopardy doctor have their own problems, such as assigning that doctor’s admissions the next day. The jeopardy doctor might provide some relief today, but they essentially just delay the work of having to get to know all of those new patients until the morning, when everyone is very busy with rounds. So while there might be significant benefit in activating the jeopardy system today, it could just delay the problem of high workload until the next morning, which isn’t much of a net benefit for the practice.

A small number of practices call in the jeopardy doctor frequently, and sometimes have that doctor continue to round on admitted patients for the next few days. This usage might get the most value out of the system, but the practice should consider if it is more cost-effective, and less stressful for the doctors, if the system were reversed. For example, instead of having the doctor on jeopardy and called in as necessary, the doctor would report to work and be given the day off or let go early when it isn’t busy.

Despite my reservations, if you are convinced the jeopardy system is valuable and cost-effective, keep it in place. However, if your group is thinking about options to handle surge capacity, don’t be too quick to adopt a jeopardy system. It usually falls far short of a perfect solution.

Patient Volume Cap

Another way to address the problem of unpredictable increases in patient volume is to establish a patient volume (e.g., total census) cap for the whole hospitalist practice. Like the jeopardy system, this is an appealingly uncomplicated idea, and hospitalists who have finished residency within the last few years all worked with a cap.

Except for the rarest of exceptions, this is a poor idea and should be avoided if at all possible. I’ll leave for another time a discussion of all the political and financial costs of a cap system, but trust me on this one. It is best to avoid a cap.

Stay Tuned …

Next month, I’ll examine other strategies to provide surge capacity. I think they’re more valuable than the two I’ve mentioned here, but I need to warn you that they aren’t perfect and are more complicated to operationalize. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelson flores.com). He is course co-director and 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.

Unpredictable workloads and frequent interruptions are the things I regard as the most stressful components of work as a hospitalist. Your list might be very different, but I bet unpredictable workloads ranks at least in the top five of every hospitalist’s list.

I’ve discussed interruptions previously (see “Really, It’s Switch-Tasking,” p. 68, November 2008; “Technological Advance or Workplace Setback?” p. 69, December 2008), but this month and next will turn to unpredictable workloads. In other words, what are the strategies available to a hospitalist practice to provide surge capacity in response to such unpredictable increases in patient volume as an uptick in census or daily admissions 50% to 100% above normal? I’ll leave to others the topic of how hospitals respond to such disasters as terrorist attacks, earthquakes, etc.

The Bottom Line

Sadly, there is no magic bullet for the “surge” problem, and no way to protect on-duty hospitalists from the need to work harder when it gets busy. But we needn’t feel too sorry for ourselves; doctors in most other specialties who practice in the hospital face the same problem and tend to rely heavily on simply working harder and longer when it is unusually busy. Sometimes they couple the “work harder” mantra with other strategies, such as calling another doctor in to help.

Hospitalists have a duty to ensure high patient volume doesn’t lead to deterioration in the quality of patient care, but occasionally working longer days than average probably poses a low risk, and might be less risky than the additional handoffs usually associated with having a doctor on “jeopardy” to be called in when it’s busy. Routinely or frequently working unreasonably long days is another story.

The trick for HM programs is to build some surge capacity into the routine daily staffing 1) without exceeding a reasonable budget, while 2) ensuring that the hospitalists don’t simply become accustomed to light workloads as the only reasonable norm, which could lead to them becoming unwilling to accept higher, but still reasonable, workloads when needed. (More on these issues later.) First, I’ll go through what I see as the pros and cons of several approaches to addressing surges in patient volume. All are in use with variable frequency around the country.

“Jeopardy” System

In its most common form, a jeopardy system has an unscheduled doctor each day who must remain available on short notice by pager. When patient volume surges, the unscheduled doctor is paged to come in and help. In most cases, this doctor focuses primarily—or exclusively—on admitting patients for a few hours. So it is most common for this doctor to be called in late in the afternoon or early in the evening. The jeopardy doctor usually turns over all admitted patients to another hospitalist in the group for all subsequent care. In addition to providing surge capacity, the jeopardy doctor almost always is used to cover unexpected absences of scheduled doctors, including illness-related absences.

Sometimes this doctor is paid extra for each day or week spent being “available” on jeopardy duty (not to be confused with jury duty, though it can be equally difficult to get exempted from). Then again, it is not uncommon to have jeopardy duty included in base compensation. However, once a jeopardy doctor is actually called in to work, most practices pay additional compensation, often based on an hourly rate that usually is higher than the average compensation generated per hour for nonjeopardy work.

There are a number of reasonable ways to compensate the jeopardy doctor. You probably can get some good ideas by talking with others in your hospital who function in a similar capacity, such as cath-lab technicians who get called in on nights and weekends.

No definitive data are available to show how common the jeopardy system is, but my experience is that 30% to 50% of HM groups use some form of it. Its popularity is proof that it is a reasonable system, but I’m not convinced. I think it is in use by a lot of groups not because it is an optimal way to ensure surge capacity, but because it is easy to conceptualize and put in place, and because many hospitalists came from residency programs in which the system was standard.

The gaps between theoretical and realized benefits become evident once a practice implements a jeopardy system. For example, it might be really busy today, but Dr. Stravinsky doesn’t call in Dr. Copeland, who is on jeopardy, because next week their roles will be reversed and Dr. Stravinsky sure hopes he won’t be called in. No one wants to be the weak doctor who calls in the jeopardy doctor and spoils what was otherwise a day off.

I’ve worked with a lot of practices who say they have a jeopardy system in place, but when I ask for the last time the jeopardy doctor was called in, they say it has been more than a year, or in some cases never. So even if the policy manual says they have a jeopardy system, the doctors never activate it, so it provides no benefit.

Practices that do utilize the jeopardy doctor have their own problems, such as assigning that doctor’s admissions the next day. The jeopardy doctor might provide some relief today, but they essentially just delay the work of having to get to know all of those new patients until the morning, when everyone is very busy with rounds. So while there might be significant benefit in activating the jeopardy system today, it could just delay the problem of high workload until the next morning, which isn’t much of a net benefit for the practice.

A small number of practices call in the jeopardy doctor frequently, and sometimes have that doctor continue to round on admitted patients for the next few days. This usage might get the most value out of the system, but the practice should consider if it is more cost-effective, and less stressful for the doctors, if the system were reversed. For example, instead of having the doctor on jeopardy and called in as necessary, the doctor would report to work and be given the day off or let go early when it isn’t busy.

Despite my reservations, if you are convinced the jeopardy system is valuable and cost-effective, keep it in place. However, if your group is thinking about options to handle surge capacity, don’t be too quick to adopt a jeopardy system. It usually falls far short of a perfect solution.

Patient Volume Cap

Another way to address the problem of unpredictable increases in patient volume is to establish a patient volume (e.g., total census) cap for the whole hospitalist practice. Like the jeopardy system, this is an appealingly uncomplicated idea, and hospitalists who have finished residency within the last few years all worked with a cap.

Except for the rarest of exceptions, this is a poor idea and should be avoided if at all possible. I’ll leave for another time a discussion of all the political and financial costs of a cap system, but trust me on this one. It is best to avoid a cap.

Stay Tuned …

Next month, I’ll examine other strategies to provide surge capacity. I think they’re more valuable than the two I’ve mentioned here, but I need to warn you that they aren’t perfect and are more complicated to operationalize. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelson flores.com). He is course co-director and 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.