One concern some have about the hospitalist model has been that it may contribute to depersonalization in healthcare. And yet, the way the Japanese people responded to the 2011 earthquake and tsunami illustrates how healthcare workers without existing patient relationships can still care deeply for patients and earn their trust.

On March 11, 2011, an earthquake of 9.0 magnitude hit northeast Japan. It was followed by a tsunami more than 45 feet tall. The world was horrified by the images of waves swallowing the coast of Japan, throwing boats and cars about like toys. As of March 2012:

• 15,854 deaths had been attributed to the earthquake;
• 3,155 people were still missing;
• More than 2.5 million houses were destroyed and
• 344,290 evacuees were still homeless.

A meltdown of nuclear reactors at the Fukushima Daiichi Nuclear Power Plant is now under way, and the country still struggles to minimize the impact of radiation contamination.

As government officials and representatives of Tokyo Electric Power Company (TEPCO), operator of the Fukushima nuclear facility, lamented they were “prepared for a tsunami 20 feet tall, but not 45 feet,” I could not help but recall a similar conversation I had years ago with one of my patients.

Working at my primary-care clinic, I was taking care of a woman who was in her fifties who had hypertension, diabetes, and hyperlipidemia. She was adherent to all of her medications and diet; she had just started swimming at the YWCA; she was a model patient whose numbers were all pristine. We did everything we could and all indications were that she was going to do very well. Yet, one day, she suffered a major stroke. “This is so unexpected,” I lamented when I saw her in the hospital.

Adversity can bring out both the best and the worst of human nature. The world witnessed diligence, solidarity, and fortitude by the Japanese following the 2011 disaster. Viewers around the world were surprised by media coverage of the affected areas, as reports showed hardly any evidence of violence or looting. Hundreds of evacuees living in a school gymnasium were engaging in morning stretches together. At mealtime, the evacuees lined up quietly, waiting for rations of food and water. They politely took turns using portable toilets and showers. Some women were taking care of the elderly while their husbands searched for missing neighbors. There was a strong sense of “we are all in this together.”

Japanese victims were able to remain resilient because they trusted in each other and in the help that ultimately arrived. For example, many people were touched by the dedication of healthcare workers who volunteered in rescue missions. According to a widely read blog posted by a nurse who participated in a mission to Rikuzen Takata, one of the most devastated areas, her team leader had warned her not to expect to eat, drink, sleep, or even use the bathroom. She had also been cautioned not to cry: “The victims are asking for our help, not sympathy.”

The nurse took care of several hundred evacuees on her first day, literally without eating, drinking, or using the bathroom. Amid her incredibly hectic day, she found comfort in making a new friend, a cute 9-year-old girl who followed her everywhere. They talked about boys and laughed together. When the nurse later discovered that the girl was following her because she had just lost her mother and her home, she could no longer endure. She cried in secret. Masking her own distress, she remained dedicated and selfless until the end, bolstering the victims with her smiles instead of tears. (Read more of the blog in English at jkts-english.blogspot.com, or read in Japanese at blog.goo.ne.jp/flower-wing.)

Such a courageous story is in stark contrast to how the government and TEPCO responded to the nuclear crisis in Fukushima. Their combined lack of leadership and inadequate disclosure of information on the risk of radiation contamination deprived them of trust from both the Japanese public and the global community, creating chaos and confusion.

Again, I was reminded of my clinic patient. After she had suffered the stroke, I was fearful that it could disrupt our therapeutic relationship. I thought I might have lost her trust. I expected her to stop listening to my recommendations. I even thought she would fire me.

To my surprise, however, she not only kept me as her physician, but also recruited her husband to become my patient. She continued to take her medications and follow a diet that I recommended. She said she liked how I continued to visit her in the hospital during her worst times. I was sincerely relieved to hear that, because it took a great deal of nerves to see her in the hospital after what had happened. Fortunately, her weakness improved significantly as she went through rehabilitation and, eventually, she recovered to the point where I could no longer tell if she had ever suffered a stroke. I believe that the trust she had in our healthcare system saved her.

In both cases, trust played an essential role. Trust can make people resilient at critical junctures because it gives them hope. The question for hospitalists then becomes how to build trust. More simply said than done, I believe that some form of personal sacrifice is necessary. This might mean that we may need to spend more time at our patients’ bedside, but it might mean that we have to make ourselves emotionally available to patients’ needs and remain compassionate.

A few years ago, I worked with an intern who spent a couple of hours with his patient during his call on a Saturday night. He was talking to an anxious patient who had just been diagnosed with advanced cancer and wanted to give up. After that night, the patient decided to stay and undergo treatment. The intern provided the patient with hope, and the patient trusted the intern. The patient is doing well today and, whenever I run into him in the hospital, he always asks about the intern.

Another intern I worked with exhibited outstanding bedside manners. She always sat down and held her patients’ hands as she explained her plans. She was kind and caring. One of her patients appreciated her and trusted her so much that he insisted on finding her a husband. We all laughed, mirthfully. Even though we could not do anything about the terminal cancer he was diagnosed with, he still left the hospital smiling.

In hospitals, we witness disasters and devastations daily. They might not be as visible as the images of earthquakes or tsunamis, but we know the impact of disease or injury is challenging. As responders to personal catastrophes, hospitalists must strive to allow our patients to trust us, trust our healthcare, and, above all, trust themselves. We have to constantly remind ourselves that the very existence of hospitalists came out of the necessity to have a readily available presence of physicians in the hospitals. We can help our patients by rededicating ourselves to the values at the heart of our profession.

Ryotaro Kato, MD, JD, is chief hospitalist at the Department of Veterans Affairs Medical Center at the Washington University School of Medicine, St. Louis.

One concern some have about the hospitalist model has been that it may contribute to depersonalization in healthcare. And yet, the way the Japanese people responded to the 2011 earthquake and tsunami illustrates how healthcare workers without existing patient relationships can still care deeply for patients and earn their trust.

On March 11, 2011, an earthquake of 9.0 magnitude hit northeast Japan. It was followed by a tsunami more than 45 feet tall. The world was horrified by the images of waves swallowing the coast of Japan, throwing boats and cars about like toys. As of March 2012:

• 15,854 deaths had been attributed to the earthquake;
• 3,155 people were still missing;
• More than 2.5 million houses were destroyed and
• 344,290 evacuees were still homeless.

A meltdown of nuclear reactors at the Fukushima Daiichi Nuclear Power Plant is now under way, and the country still struggles to minimize the impact of radiation contamination.

As government officials and representatives of Tokyo Electric Power Company (TEPCO), operator of the Fukushima nuclear facility, lamented they were “prepared for a tsunami 20 feet tall, but not 45 feet,” I could not help but recall a similar conversation I had years ago with one of my patients.

Working at my primary-care clinic, I was taking care of a woman who was in her fifties who had hypertension, diabetes, and hyperlipidemia. She was adherent to all of her medications and diet; she had just started swimming at the YWCA; she was a model patient whose numbers were all pristine. We did everything we could and all indications were that she was going to do very well. Yet, one day, she suffered a major stroke. “This is so unexpected,” I lamented when I saw her in the hospital.

Adversity can bring out both the best and the worst of human nature. The world witnessed diligence, solidarity, and fortitude by the Japanese following the 2011 disaster. Viewers around the world were surprised by media coverage of the affected areas, as reports showed hardly any evidence of violence or looting. Hundreds of evacuees living in a school gymnasium were engaging in morning stretches together. At mealtime, the evacuees lined up quietly, waiting for rations of food and water. They politely took turns using portable toilets and showers. Some women were taking care of the elderly while their husbands searched for missing neighbors. There was a strong sense of “we are all in this together.”

Japanese victims were able to remain resilient because they trusted in each other and in the help that ultimately arrived. For example, many people were touched by the dedication of healthcare workers who volunteered in rescue missions. According to a widely read blog posted by a nurse who participated in a mission to Rikuzen Takata, one of the most devastated areas, her team leader had warned her not to expect to eat, drink, sleep, or even use the bathroom. She had also been cautioned not to cry: “The victims are asking for our help, not sympathy.”

The nurse took care of several hundred evacuees on her first day, literally without eating, drinking, or using the bathroom. Amid her incredibly hectic day, she found comfort in making a new friend, a cute 9-year-old girl who followed her everywhere. They talked about boys and laughed together. When the nurse later discovered that the girl was following her because she had just lost her mother and her home, she could no longer endure. She cried in secret. Masking her own distress, she remained dedicated and selfless until the end, bolstering the victims with her smiles instead of tears. (Read more of the blog in English at jkts-english.blogspot.com, or read in Japanese at blog.goo.ne.jp/flower-wing.)

Such a courageous story is in stark contrast to how the government and TEPCO responded to the nuclear crisis in Fukushima. Their combined lack of leadership and inadequate disclosure of information on the risk of radiation contamination deprived them of trust from both the Japanese public and the global community, creating chaos and confusion.

Again, I was reminded of my clinic patient. After she had suffered the stroke, I was fearful that it could disrupt our therapeutic relationship. I thought I might have lost her trust. I expected her to stop listening to my recommendations. I even thought she would fire me.

To my surprise, however, she not only kept me as her physician, but also recruited her husband to become my patient. She continued to take her medications and follow a diet that I recommended. She said she liked how I continued to visit her in the hospital during her worst times. I was sincerely relieved to hear that, because it took a great deal of nerves to see her in the hospital after what had happened. Fortunately, her weakness improved significantly as she went through rehabilitation and, eventually, she recovered to the point where I could no longer tell if she had ever suffered a stroke. I believe that the trust she had in our healthcare system saved her.

In both cases, trust played an essential role. Trust can make people resilient at critical junctures because it gives them hope. The question for hospitalists then becomes how to build trust. More simply said than done, I believe that some form of personal sacrifice is necessary. This might mean that we may need to spend more time at our patients’ bedside, but it might mean that we have to make ourselves emotionally available to patients’ needs and remain compassionate.

A few years ago, I worked with an intern who spent a couple of hours with his patient during his call on a Saturday night. He was talking to an anxious patient who had just been diagnosed with advanced cancer and wanted to give up. After that night, the patient decided to stay and undergo treatment. The intern provided the patient with hope, and the patient trusted the intern. The patient is doing well today and, whenever I run into him in the hospital, he always asks about the intern.

Another intern I worked with exhibited outstanding bedside manners. She always sat down and held her patients’ hands as she explained her plans. She was kind and caring. One of her patients appreciated her and trusted her so much that he insisted on finding her a husband. We all laughed, mirthfully. Even though we could not do anything about the terminal cancer he was diagnosed with, he still left the hospital smiling.

In hospitals, we witness disasters and devastations daily. They might not be as visible as the images of earthquakes or tsunamis, but we know the impact of disease or injury is challenging. As responders to personal catastrophes, hospitalists must strive to allow our patients to trust us, trust our healthcare, and, above all, trust themselves. We have to constantly remind ourselves that the very existence of hospitalists came out of the necessity to have a readily available presence of physicians in the hospitals. We can help our patients by rededicating ourselves to the values at the heart of our profession.

Ryotaro Kato, MD, JD, is chief hospitalist at the Department of Veterans Affairs Medical Center at the Washington University School of Medicine, St. Louis.

One concern some have about the hospitalist model has been that it may contribute to depersonalization in healthcare. And yet, the way the Japanese people responded to the 2011 earthquake and tsunami illustrates how healthcare workers without existing patient relationships can still care deeply for patients and earn their trust.

On March 11, 2011, an earthquake of 9.0 magnitude hit northeast Japan. It was followed by a tsunami more than 45 feet tall. The world was horrified by the images of waves swallowing the coast of Japan, throwing boats and cars about like toys. As of March 2012:

• 15,854 deaths had been attributed to the earthquake;
• 3,155 people were still missing;
• More than 2.5 million houses were destroyed and
• 344,290 evacuees were still homeless.

A meltdown of nuclear reactors at the Fukushima Daiichi Nuclear Power Plant is now under way, and the country still struggles to minimize the impact of radiation contamination.

As government officials and representatives of Tokyo Electric Power Company (TEPCO), operator of the Fukushima nuclear facility, lamented they were “prepared for a tsunami 20 feet tall, but not 45 feet,” I could not help but recall a similar conversation I had years ago with one of my patients.

Working at my primary-care clinic, I was taking care of a woman who was in her fifties who had hypertension, diabetes, and hyperlipidemia. She was adherent to all of her medications and diet; she had just started swimming at the YWCA; she was a model patient whose numbers were all pristine. We did everything we could and all indications were that she was going to do very well. Yet, one day, she suffered a major stroke. “This is so unexpected,” I lamented when I saw her in the hospital.

Adversity can bring out both the best and the worst of human nature. The world witnessed diligence, solidarity, and fortitude by the Japanese following the 2011 disaster. Viewers around the world were surprised by media coverage of the affected areas, as reports showed hardly any evidence of violence or looting. Hundreds of evacuees living in a school gymnasium were engaging in morning stretches together. At mealtime, the evacuees lined up quietly, waiting for rations of food and water. They politely took turns using portable toilets and showers. Some women were taking care of the elderly while their husbands searched for missing neighbors. There was a strong sense of “we are all in this together.”

Japanese victims were able to remain resilient because they trusted in each other and in the help that ultimately arrived. For example, many people were touched by the dedication of healthcare workers who volunteered in rescue missions. According to a widely read blog posted by a nurse who participated in a mission to Rikuzen Takata, one of the most devastated areas, her team leader had warned her not to expect to eat, drink, sleep, or even use the bathroom. She had also been cautioned not to cry: “The victims are asking for our help, not sympathy.”

The nurse took care of several hundred evacuees on her first day, literally without eating, drinking, or using the bathroom. Amid her incredibly hectic day, she found comfort in making a new friend, a cute 9-year-old girl who followed her everywhere. They talked about boys and laughed together. When the nurse later discovered that the girl was following her because she had just lost her mother and her home, she could no longer endure. She cried in secret. Masking her own distress, she remained dedicated and selfless until the end, bolstering the victims with her smiles instead of tears. (Read more of the blog in English at jkts-english.blogspot.com, or read in Japanese at blog.goo.ne.jp/flower-wing.)

Such a courageous story is in stark contrast to how the government and TEPCO responded to the nuclear crisis in Fukushima. Their combined lack of leadership and inadequate disclosure of information on the risk of radiation contamination deprived them of trust from both the Japanese public and the global community, creating chaos and confusion.

Again, I was reminded of my clinic patient. After she had suffered the stroke, I was fearful that it could disrupt our therapeutic relationship. I thought I might have lost her trust. I expected her to stop listening to my recommendations. I even thought she would fire me.

To my surprise, however, she not only kept me as her physician, but also recruited her husband to become my patient. She continued to take her medications and follow a diet that I recommended. She said she liked how I continued to visit her in the hospital during her worst times. I was sincerely relieved to hear that, because it took a great deal of nerves to see her in the hospital after what had happened. Fortunately, her weakness improved significantly as she went through rehabilitation and, eventually, she recovered to the point where I could no longer tell if she had ever suffered a stroke. I believe that the trust she had in our healthcare system saved her.

In both cases, trust played an essential role. Trust can make people resilient at critical junctures because it gives them hope. The question for hospitalists then becomes how to build trust. More simply said than done, I believe that some form of personal sacrifice is necessary. This might mean that we may need to spend more time at our patients’ bedside, but it might mean that we have to make ourselves emotionally available to patients’ needs and remain compassionate.

A few years ago, I worked with an intern who spent a couple of hours with his patient during his call on a Saturday night. He was talking to an anxious patient who had just been diagnosed with advanced cancer and wanted to give up. After that night, the patient decided to stay and undergo treatment. The intern provided the patient with hope, and the patient trusted the intern. The patient is doing well today and, whenever I run into him in the hospital, he always asks about the intern.

Another intern I worked with exhibited outstanding bedside manners. She always sat down and held her patients’ hands as she explained her plans. She was kind and caring. One of her patients appreciated her and trusted her so much that he insisted on finding her a husband. We all laughed, mirthfully. Even though we could not do anything about the terminal cancer he was diagnosed with, he still left the hospital smiling.

In hospitals, we witness disasters and devastations daily. They might not be as visible as the images of earthquakes or tsunamis, but we know the impact of disease or injury is challenging. As responders to personal catastrophes, hospitalists must strive to allow our patients to trust us, trust our healthcare, and, above all, trust themselves. We have to constantly remind ourselves that the very existence of hospitalists came out of the necessity to have a readily available presence of physicians in the hospitals. We can help our patients by rededicating ourselves to the values at the heart of our profession.

Ryotaro Kato, MD, JD, is chief hospitalist at the Department of Veterans Affairs Medical Center at the Washington University School of Medicine, St. Louis.

Hospital medicine is 15 years old now and, as the fastest-growing medical specialty, has created innovation and excitement in healthcare. With more than 34,000 hospitalists at more than 4,000 hospitals, hospitalists are now an accepted part of the medical community. But clearly HM is still a work in progress, with our best days still ahead of us.

So what’s in store for us as we look to the next five to 10 years?

First, it is important to note that the very institution of the hospital is evolving. Hospitals no longer are defined by the walls of their buildings; hospitals view themselves as significant community resources along a continuum of care that includes care when the patient is horizontally confined during an acute illness. Just as hospitals need to be involved in the care of the community (e.g. to reduce preventable readmissions or ED visits), so too hospitalists’ scope of practice is expanding.

Expanding HM Scope

At one time, long, long ago, the scope of hospitalists’ work could be narrowly defined as the care of the acutely ill patient with such a medical illness as heart failure or pneumonia. Today, hospitalists routinely comanage surgical problems and serve as the prime admitter for medical cases (acute chest pain, sepsis, and the like) previously sent directly to specialists.

As surgeons and specialists have narrowed their practices, hospitalists have been called on to be proceduralists, inserting central lines and even doing bedside ultrasound. With a decreasing workforce of critical-care-trained physicians, hospitalists are being challenged to provide an ever-increasing amount of critical care, a phenomenon that will increase in the future and further stretch the competencies and training of most hospitalists.

At the edges of acute care, hospitalists are being called upon to augment the “neighborhood” around the patient-centered medical home. In some settings, hospitalists now provide the initial post-discharge, follow-up outpatient visits to “complete” the hospitalization, stabilize the patient, and transition them back to their community provider. CareMore Health Plan in California is setting the standard for this transitionalist role, also known as an “extensivist.” As the demand from hospitals and payors to reduce post-discharge bounce-back to the ED or to be readmitted increases, hospitalists and the medical home will need to carefully coordinate their roles if HM is to provide our patients (and their families) with what they need and expect—a smooth, coordinated transition from the hospital to home with clear communication and accountability

Fulfill the Promise

To do this, and do this well, hospitalists will need to fulfill our promise. We have spent the last decade positioning hospitalists as having two patients: the clinical care of the patient in front of us and the improvement of the system we work in. We have acknowledged that most hospitalists don’t come out of residency, or even years in practice, with all the skills needed for this unique and important role.

In many ways, SHM has become the society of “everything you didn’t learn in training that you found out you need to know in practice.” SHM has trained more than 2,000 hospitalists in our Leadership Academies. We have expanded our annual-meeting course offerings to include perioperative care, neurology, critical care, and procedures.

Through the Center for Hospital Improvement and Innovation, SHM has developed courses in quality-improvement (QI) skills and processes, as well as support and tactics for helping hospitalists make real change at their institutions through SHM’s mentored implementation in transitions of care (Project BOOST), preventing DVT, and improving glycemic control.

But even with SHM and many other organizations touching thousands of hospitalists, the HM landscape is varied. Some hospitalist groups are well-formed, well-staffed and supported, and they are delivering on the full promise of HM today. Yet many HM groups are very much a work in progress.

This is not surprising when you realize that the role of hospitalists has been evolving in real time while the hospitals we all work in are changing as well. Throw into the mix the addition of more than 30,000 hospitalists over the last decade with various training, skills, and experience, and it is not unexpected that the results have been a mixed bag.

In the next decade, however, HM groups will need to step up their game to fulfill the promise of HM more broadly in our nation’s hospitals. SHM hopes to provide a guidepost in this process and is considering developing standards for HM groups (HMGs) and possibly creating an aspirational award along the lines of the Baldrige Award. At the beginning, maybe only a few hundred HMGs will qualify for such an award, but the hope is that other HMGs will use this opportunity to obtain the resources and make the improvements to also achieve the highest standard for hospitalists.

A Perfect Partner

At the same time, it is clear that both the government and private insurers are heading toward a new way to pay for healthcare, moving away from the current transactional manner in which the procedure and the visit is the currency, to something where value and performance become crucial.

This is a system in which preventing the DVT is more valued than waiting for the complication and treating it, where doing the first hospitalization right and working with the family and the patient to make the best transition out of the hospital is rewarded more than billing the insurer for the readmission.

The efficient and competent HM group is an ideal partner for the hospital in this future world.

In addition, the hospital community is being reshaped. More and more physicians are gravitating to the hospital as an employee or essential partner. More than 70% of cardiologists are now hospital-employed. Specialty hospitalists, most notably in the fields of OBGYN, neurology, orthopedics, surgery, and psychiatry, are growing.

Accountable-care organizations (ACOs) are being supported by Medicare and should continue to grow as another hospital-physician risk-sharing entity. In many places, hospitalists have been in place for more than 10 years as the original physician partners with their hospitals. It is very likely that hospitalists will be right in the middle of the new medical staff and in driving the expected efficiencies and improvements as the hospital of the future and payment system changes continue to evolve.

In all of this, it is important for HM to continue to be creative and innovative, and not hamstrung by the conventional and the status quo. This calls for more than just fresh ideas and the courage to be bold. It requires new skills and competencies. We must continue to knock down the barriers of autonomy and exchange that for active participation in, and leadership of, the team. We must continue to move away from the mystique of the physician and embrace the need to set a course for change, be willing to be measured and be less than perfect, and seize the opportunity to improve and innovate.

Although the last decade of HM has been no piece of cake, the next 10 years will be even more challenging. The good news is that our skills and competencies can make us a central player, a key partner. But we will need to rise to meet this challenge.

Dr. Wellikson is CEO of SHM.

Hospital medicine is 15 years old now and, as the fastest-growing medical specialty, has created innovation and excitement in healthcare. With more than 34,000 hospitalists at more than 4,000 hospitals, hospitalists are now an accepted part of the medical community. But clearly HM is still a work in progress, with our best days still ahead of us.

So what’s in store for us as we look to the next five to 10 years?

First, it is important to note that the very institution of the hospital is evolving. Hospitals no longer are defined by the walls of their buildings; hospitals view themselves as significant community resources along a continuum of care that includes care when the patient is horizontally confined during an acute illness. Just as hospitals need to be involved in the care of the community (e.g. to reduce preventable readmissions or ED visits), so too hospitalists’ scope of practice is expanding.

Expanding HM Scope

At one time, long, long ago, the scope of hospitalists’ work could be narrowly defined as the care of the acutely ill patient with such a medical illness as heart failure or pneumonia. Today, hospitalists routinely comanage surgical problems and serve as the prime admitter for medical cases (acute chest pain, sepsis, and the like) previously sent directly to specialists.

As surgeons and specialists have narrowed their practices, hospitalists have been called on to be proceduralists, inserting central lines and even doing bedside ultrasound. With a decreasing workforce of critical-care-trained physicians, hospitalists are being challenged to provide an ever-increasing amount of critical care, a phenomenon that will increase in the future and further stretch the competencies and training of most hospitalists.

At the edges of acute care, hospitalists are being called upon to augment the “neighborhood” around the patient-centered medical home. In some settings, hospitalists now provide the initial post-discharge, follow-up outpatient visits to “complete” the hospitalization, stabilize the patient, and transition them back to their community provider. CareMore Health Plan in California is setting the standard for this transitionalist role, also known as an “extensivist.” As the demand from hospitals and payors to reduce post-discharge bounce-back to the ED or to be readmitted increases, hospitalists and the medical home will need to carefully coordinate their roles if HM is to provide our patients (and their families) with what they need and expect—a smooth, coordinated transition from the hospital to home with clear communication and accountability

Fulfill the Promise

To do this, and do this well, hospitalists will need to fulfill our promise. We have spent the last decade positioning hospitalists as having two patients: the clinical care of the patient in front of us and the improvement of the system we work in. We have acknowledged that most hospitalists don’t come out of residency, or even years in practice, with all the skills needed for this unique and important role.

In many ways, SHM has become the society of “everything you didn’t learn in training that you found out you need to know in practice.” SHM has trained more than 2,000 hospitalists in our Leadership Academies. We have expanded our annual-meeting course offerings to include perioperative care, neurology, critical care, and procedures.

Through the Center for Hospital Improvement and Innovation, SHM has developed courses in quality-improvement (QI) skills and processes, as well as support and tactics for helping hospitalists make real change at their institutions through SHM’s mentored implementation in transitions of care (Project BOOST), preventing DVT, and improving glycemic control.

But even with SHM and many other organizations touching thousands of hospitalists, the HM landscape is varied. Some hospitalist groups are well-formed, well-staffed and supported, and they are delivering on the full promise of HM today. Yet many HM groups are very much a work in progress.

This is not surprising when you realize that the role of hospitalists has been evolving in real time while the hospitals we all work in are changing as well. Throw into the mix the addition of more than 30,000 hospitalists over the last decade with various training, skills, and experience, and it is not unexpected that the results have been a mixed bag.

In the next decade, however, HM groups will need to step up their game to fulfill the promise of HM more broadly in our nation’s hospitals. SHM hopes to provide a guidepost in this process and is considering developing standards for HM groups (HMGs) and possibly creating an aspirational award along the lines of the Baldrige Award. At the beginning, maybe only a few hundred HMGs will qualify for such an award, but the hope is that other HMGs will use this opportunity to obtain the resources and make the improvements to also achieve the highest standard for hospitalists.

A Perfect Partner

At the same time, it is clear that both the government and private insurers are heading toward a new way to pay for healthcare, moving away from the current transactional manner in which the procedure and the visit is the currency, to something where value and performance become crucial.

This is a system in which preventing the DVT is more valued than waiting for the complication and treating it, where doing the first hospitalization right and working with the family and the patient to make the best transition out of the hospital is rewarded more than billing the insurer for the readmission.

The efficient and competent HM group is an ideal partner for the hospital in this future world.

In addition, the hospital community is being reshaped. More and more physicians are gravitating to the hospital as an employee or essential partner. More than 70% of cardiologists are now hospital-employed. Specialty hospitalists, most notably in the fields of OBGYN, neurology, orthopedics, surgery, and psychiatry, are growing.

Accountable-care organizations (ACOs) are being supported by Medicare and should continue to grow as another hospital-physician risk-sharing entity. In many places, hospitalists have been in place for more than 10 years as the original physician partners with their hospitals. It is very likely that hospitalists will be right in the middle of the new medical staff and in driving the expected efficiencies and improvements as the hospital of the future and payment system changes continue to evolve.

In all of this, it is important for HM to continue to be creative and innovative, and not hamstrung by the conventional and the status quo. This calls for more than just fresh ideas and the courage to be bold. It requires new skills and competencies. We must continue to knock down the barriers of autonomy and exchange that for active participation in, and leadership of, the team. We must continue to move away from the mystique of the physician and embrace the need to set a course for change, be willing to be measured and be less than perfect, and seize the opportunity to improve and innovate.

Although the last decade of HM has been no piece of cake, the next 10 years will be even more challenging. The good news is that our skills and competencies can make us a central player, a key partner. But we will need to rise to meet this challenge.

Dr. Wellikson is CEO of SHM.

Hospital medicine is 15 years old now and, as the fastest-growing medical specialty, has created innovation and excitement in healthcare. With more than 34,000 hospitalists at more than 4,000 hospitals, hospitalists are now an accepted part of the medical community. But clearly HM is still a work in progress, with our best days still ahead of us.

So what’s in store for us as we look to the next five to 10 years?

First, it is important to note that the very institution of the hospital is evolving. Hospitals no longer are defined by the walls of their buildings; hospitals view themselves as significant community resources along a continuum of care that includes care when the patient is horizontally confined during an acute illness. Just as hospitals need to be involved in the care of the community (e.g. to reduce preventable readmissions or ED visits), so too hospitalists’ scope of practice is expanding.

Expanding HM Scope

At one time, long, long ago, the scope of hospitalists’ work could be narrowly defined as the care of the acutely ill patient with such a medical illness as heart failure or pneumonia. Today, hospitalists routinely comanage surgical problems and serve as the prime admitter for medical cases (acute chest pain, sepsis, and the like) previously sent directly to specialists.

As surgeons and specialists have narrowed their practices, hospitalists have been called on to be proceduralists, inserting central lines and even doing bedside ultrasound. With a decreasing workforce of critical-care-trained physicians, hospitalists are being challenged to provide an ever-increasing amount of critical care, a phenomenon that will increase in the future and further stretch the competencies and training of most hospitalists.

At the edges of acute care, hospitalists are being called upon to augment the “neighborhood” around the patient-centered medical home. In some settings, hospitalists now provide the initial post-discharge, follow-up outpatient visits to “complete” the hospitalization, stabilize the patient, and transition them back to their community provider. CareMore Health Plan in California is setting the standard for this transitionalist role, also known as an “extensivist.” As the demand from hospitals and payors to reduce post-discharge bounce-back to the ED or to be readmitted increases, hospitalists and the medical home will need to carefully coordinate their roles if HM is to provide our patients (and their families) with what they need and expect—a smooth, coordinated transition from the hospital to home with clear communication and accountability

Fulfill the Promise

To do this, and do this well, hospitalists will need to fulfill our promise. We have spent the last decade positioning hospitalists as having two patients: the clinical care of the patient in front of us and the improvement of the system we work in. We have acknowledged that most hospitalists don’t come out of residency, or even years in practice, with all the skills needed for this unique and important role.

In many ways, SHM has become the society of “everything you didn’t learn in training that you found out you need to know in practice.” SHM has trained more than 2,000 hospitalists in our Leadership Academies. We have expanded our annual-meeting course offerings to include perioperative care, neurology, critical care, and procedures.

Through the Center for Hospital Improvement and Innovation, SHM has developed courses in quality-improvement (QI) skills and processes, as well as support and tactics for helping hospitalists make real change at their institutions through SHM’s mentored implementation in transitions of care (Project BOOST), preventing DVT, and improving glycemic control.

But even with SHM and many other organizations touching thousands of hospitalists, the HM landscape is varied. Some hospitalist groups are well-formed, well-staffed and supported, and they are delivering on the full promise of HM today. Yet many HM groups are very much a work in progress.

This is not surprising when you realize that the role of hospitalists has been evolving in real time while the hospitals we all work in are changing as well. Throw into the mix the addition of more than 30,000 hospitalists over the last decade with various training, skills, and experience, and it is not unexpected that the results have been a mixed bag.

In the next decade, however, HM groups will need to step up their game to fulfill the promise of HM more broadly in our nation’s hospitals. SHM hopes to provide a guidepost in this process and is considering developing standards for HM groups (HMGs) and possibly creating an aspirational award along the lines of the Baldrige Award. At the beginning, maybe only a few hundred HMGs will qualify for such an award, but the hope is that other HMGs will use this opportunity to obtain the resources and make the improvements to also achieve the highest standard for hospitalists.

A Perfect Partner

At the same time, it is clear that both the government and private insurers are heading toward a new way to pay for healthcare, moving away from the current transactional manner in which the procedure and the visit is the currency, to something where value and performance become crucial.

This is a system in which preventing the DVT is more valued than waiting for the complication and treating it, where doing the first hospitalization right and working with the family and the patient to make the best transition out of the hospital is rewarded more than billing the insurer for the readmission.

The efficient and competent HM group is an ideal partner for the hospital in this future world.

In addition, the hospital community is being reshaped. More and more physicians are gravitating to the hospital as an employee or essential partner. More than 70% of cardiologists are now hospital-employed. Specialty hospitalists, most notably in the fields of OBGYN, neurology, orthopedics, surgery, and psychiatry, are growing.

Accountable-care organizations (ACOs) are being supported by Medicare and should continue to grow as another hospital-physician risk-sharing entity. In many places, hospitalists have been in place for more than 10 years as the original physician partners with their hospitals. It is very likely that hospitalists will be right in the middle of the new medical staff and in driving the expected efficiencies and improvements as the hospital of the future and payment system changes continue to evolve.

In all of this, it is important for HM to continue to be creative and innovative, and not hamstrung by the conventional and the status quo. This calls for more than just fresh ideas and the courage to be bold. It requires new skills and competencies. We must continue to knock down the barriers of autonomy and exchange that for active participation in, and leadership of, the team. We must continue to move away from the mystique of the physician and embrace the need to set a course for change, be willing to be measured and be less than perfect, and seize the opportunity to improve and innovate.

Although the last decade of HM has been no piece of cake, the next 10 years will be even more challenging. The good news is that our skills and competencies can make us a central player, a key partner. But we will need to rise to meet this challenge.

Dr. Wellikson is CEO of SHM.

It might seem like a stretch, but my recent encounters with clothes dryers have taught me a few lessons about what HM groups need to function at their highest level:

• We need to know one another;
• We need to undergo routine maintenance; and
• We need to not get overworked.

I’ve had pretty bad luck with clothes dryers. Washing machines, no problem; I find them cooperative, reliable, long-lasting. But dryers and I are perfectly incompatible.

So I should have known I was in for problems when, last summer, we moved into a house with an old conveyed dryer. After closing on the house, I became the proud owner of the off-white, rust-tinted clothes dryer, along with the expired warranty and a stack of maintenance books. It motored along fine for a while, unattended by me (or anyone else in my household), until one day it just stopped. It stalled, mid-load, leaving inside a huge lump of wet clothes, and another, wetter load waiting in the washer.

So, not terribly surprised by yet another unreliable appliance but annoyed nonetheless, I Googled “dryer repair, Charleston, South Carolina.” A millisecond later, I found what seemed like a reputable, appealing name. Feeling like I was supporting local small business, I dialed the number and heard on the other end of a crackly landline the voice of “Fred,” his name changed to protect the innocent. After a few minutes on the phone with Fred, I imagined (later to be confirmed) a local Southern man with a broad-based baseball cap, low-riding jeans with a large belt buckle, and a knack for dryer-sized appliances.

His first logical question after my plea for help was: “What kinda dryer you got?” Hmmm, good question, since I never actually paid attention. Maytag? GE? “Umm,” I answered, “not sure.” Fred then uttered the next most logical question, this time sounding slightly annoyed: “Gas or electric?” Now you are getting a sense of how much time I spend around my dryer: “Umm, not sure.”

There was a pause on the other end of the line, and a pit in my stomach. I was thinking, “I can’t believe I am failing a screening test for this darn appliance.” As I considered making up an answer, he broke the silence: “Well … then I guess I’ll just have to pay you a visit.”

Lesson: It is pretty hard to take good care of your dryer, or to fix it when it breaks, if you don’t know too much about it. HM groups need to get to know each other, to have an understanding of what we are made of, and how we can help each other when in need of “repair.”

Tender, Loving Care

When Fred arrived at my house, he thoroughly disarticulated the dryer into remarkably small pieces. It didn’t take long after to find the culprit. There was enough lint built up around the innards to ignite a large factory.

Feeling a little defensive about my lack of dryer maintenance, I launched into a litany of complaints about my husband. “He doesn’t believe in lint traps, thinks cleaning them is beyond a nuisance, and only resorts to the task when gray dust bunnies are bulging out of the top.” It was about this time that Fred, with years of old-fashioned Southern wisdom, pointed out to me that I was lucky to have a husband that goes near a dryer; based on one-too-many husband-complaint sessions with friends, Fred had a pretty good point.

Fred was visibly disgusted with the lack of maintenance and care of this trusted appliance, because, as he later disclosed, he doesn’t just fix dryers, he actually loves dryers, which is respectable in a strange sort of way. I felt a surge of Catholic guilt about my lack of maintenance, so I vowed to Fred to take care of my dryer with all my ability, and thanked him for a job well done.

Lesson: If you don’t regularly maintain the lint trap, it all builds up on the inside, which can ignite a fire. HM groups need to regularly participate in “maintenance” functions, to keep the group humming along without risk of combustion. Such maintenance should include evaluation of roles, responsibilities, and reimbursement structures that result in equity and longevity.

The Smart Squeeze

After a few weeks of peace and harmony in the Scheurer household, without a single school uniform being re-worn with a ketchup stain, again, the unspeakable happened. An entire load of wet laundry sat in the dryer, stuck in park, with a wetter load in the washer. I flipped the switch; nothing happened. This time I even went so far as to “pop the hood,” just to look around (not that I knew what I was looking for). Without an obvious defect glaring at me, I closed the hood and, hesitantly, called Fred.

He promptly returned, on a Saturday morning, to my dwelling, and began the disarticulation process again. But before the third screw was off, he yelled, “Aha!”

Now, I wasn’t sure if the “aha” was going to translate into a “once again, you have proven yourself incapable of maintaining a simple appliance” when he disclosed, “the belt’s broke.”

What a relief; the belt broke. Surely I had no culpability for a broken belt. Alas, the broken belt had little to do with the uncooperative dryer; the belt broke because I had overloaded the old, pitiful thing. In an attempt at efficiency, I threw in a big, sopping load of towels, at least half a dozen too many, topped off with a bath mat.

Lesson: There is only so much efficiency you can squeeze out of a hospitalist group. If you load it up too heavy, it will break.

Take Stock of Your ‘Appliance’

So you see, hospitalist groups really are a lot like dryers: hundreds of brands and model types, differing slightly in maintenance requirements and load-bearing abilities, but all sharing some common denominators: a need to be understood, a need to be maintained, and a need to not be overloaded.

So ask yourself the following questions about your group:

• Do we know what brands we have?
• Are we cleaning out our lint?
• Are we breaking some belts?

If you don’t know the answers, you should probably find out...or else call Fred.

Dr. Scheurer is physician editor of The Hospitalist. Email her at scheured@musc.edu.

It might seem like a stretch, but my recent encounters with clothes dryers have taught me a few lessons about what HM groups need to function at their highest level:

• We need to know one another;
• We need to undergo routine maintenance; and
• We need to not get overworked.

I’ve had pretty bad luck with clothes dryers. Washing machines, no problem; I find them cooperative, reliable, long-lasting. But dryers and I are perfectly incompatible.

So I should have known I was in for problems when, last summer, we moved into a house with an old conveyed dryer. After closing on the house, I became the proud owner of the off-white, rust-tinted clothes dryer, along with the expired warranty and a stack of maintenance books. It motored along fine for a while, unattended by me (or anyone else in my household), until one day it just stopped. It stalled, mid-load, leaving inside a huge lump of wet clothes, and another, wetter load waiting in the washer.

So, not terribly surprised by yet another unreliable appliance but annoyed nonetheless, I Googled “dryer repair, Charleston, South Carolina.” A millisecond later, I found what seemed like a reputable, appealing name. Feeling like I was supporting local small business, I dialed the number and heard on the other end of a crackly landline the voice of “Fred,” his name changed to protect the innocent. After a few minutes on the phone with Fred, I imagined (later to be confirmed) a local Southern man with a broad-based baseball cap, low-riding jeans with a large belt buckle, and a knack for dryer-sized appliances.

His first logical question after my plea for help was: “What kinda dryer you got?” Hmmm, good question, since I never actually paid attention. Maytag? GE? “Umm,” I answered, “not sure.” Fred then uttered the next most logical question, this time sounding slightly annoyed: “Gas or electric?” Now you are getting a sense of how much time I spend around my dryer: “Umm, not sure.”

There was a pause on the other end of the line, and a pit in my stomach. I was thinking, “I can’t believe I am failing a screening test for this darn appliance.” As I considered making up an answer, he broke the silence: “Well … then I guess I’ll just have to pay you a visit.”

Lesson: It is pretty hard to take good care of your dryer, or to fix it when it breaks, if you don’t know too much about it. HM groups need to get to know each other, to have an understanding of what we are made of, and how we can help each other when in need of “repair.”

Tender, Loving Care

When Fred arrived at my house, he thoroughly disarticulated the dryer into remarkably small pieces. It didn’t take long after to find the culprit. There was enough lint built up around the innards to ignite a large factory.

Feeling a little defensive about my lack of dryer maintenance, I launched into a litany of complaints about my husband. “He doesn’t believe in lint traps, thinks cleaning them is beyond a nuisance, and only resorts to the task when gray dust bunnies are bulging out of the top.” It was about this time that Fred, with years of old-fashioned Southern wisdom, pointed out to me that I was lucky to have a husband that goes near a dryer; based on one-too-many husband-complaint sessions with friends, Fred had a pretty good point.

Fred was visibly disgusted with the lack of maintenance and care of this trusted appliance, because, as he later disclosed, he doesn’t just fix dryers, he actually loves dryers, which is respectable in a strange sort of way. I felt a surge of Catholic guilt about my lack of maintenance, so I vowed to Fred to take care of my dryer with all my ability, and thanked him for a job well done.

Lesson: If you don’t regularly maintain the lint trap, it all builds up on the inside, which can ignite a fire. HM groups need to regularly participate in “maintenance” functions, to keep the group humming along without risk of combustion. Such maintenance should include evaluation of roles, responsibilities, and reimbursement structures that result in equity and longevity.

The Smart Squeeze

After a few weeks of peace and harmony in the Scheurer household, without a single school uniform being re-worn with a ketchup stain, again, the unspeakable happened. An entire load of wet laundry sat in the dryer, stuck in park, with a wetter load in the washer. I flipped the switch; nothing happened. This time I even went so far as to “pop the hood,” just to look around (not that I knew what I was looking for). Without an obvious defect glaring at me, I closed the hood and, hesitantly, called Fred.

He promptly returned, on a Saturday morning, to my dwelling, and began the disarticulation process again. But before the third screw was off, he yelled, “Aha!”

Now, I wasn’t sure if the “aha” was going to translate into a “once again, you have proven yourself incapable of maintaining a simple appliance” when he disclosed, “the belt’s broke.”

What a relief; the belt broke. Surely I had no culpability for a broken belt. Alas, the broken belt had little to do with the uncooperative dryer; the belt broke because I had overloaded the old, pitiful thing. In an attempt at efficiency, I threw in a big, sopping load of towels, at least half a dozen too many, topped off with a bath mat.

Lesson: There is only so much efficiency you can squeeze out of a hospitalist group. If you load it up too heavy, it will break.

Take Stock of Your ‘Appliance’

So you see, hospitalist groups really are a lot like dryers: hundreds of brands and model types, differing slightly in maintenance requirements and load-bearing abilities, but all sharing some common denominators: a need to be understood, a need to be maintained, and a need to not be overloaded.

So ask yourself the following questions about your group:

• Do we know what brands we have?
• Are we cleaning out our lint?
• Are we breaking some belts?

If you don’t know the answers, you should probably find out...or else call Fred.

Dr. Scheurer is physician editor of The Hospitalist. Email her at scheured@musc.edu.

It might seem like a stretch, but my recent encounters with clothes dryers have taught me a few lessons about what HM groups need to function at their highest level:

• We need to know one another;
• We need to undergo routine maintenance; and
• We need to not get overworked.

I’ve had pretty bad luck with clothes dryers. Washing machines, no problem; I find them cooperative, reliable, long-lasting. But dryers and I are perfectly incompatible.

So I should have known I was in for problems when, last summer, we moved into a house with an old conveyed dryer. After closing on the house, I became the proud owner of the off-white, rust-tinted clothes dryer, along with the expired warranty and a stack of maintenance books. It motored along fine for a while, unattended by me (or anyone else in my household), until one day it just stopped. It stalled, mid-load, leaving inside a huge lump of wet clothes, and another, wetter load waiting in the washer.

So, not terribly surprised by yet another unreliable appliance but annoyed nonetheless, I Googled “dryer repair, Charleston, South Carolina.” A millisecond later, I found what seemed like a reputable, appealing name. Feeling like I was supporting local small business, I dialed the number and heard on the other end of a crackly landline the voice of “Fred,” his name changed to protect the innocent. After a few minutes on the phone with Fred, I imagined (later to be confirmed) a local Southern man with a broad-based baseball cap, low-riding jeans with a large belt buckle, and a knack for dryer-sized appliances.

His first logical question after my plea for help was: “What kinda dryer you got?” Hmmm, good question, since I never actually paid attention. Maytag? GE? “Umm,” I answered, “not sure.” Fred then uttered the next most logical question, this time sounding slightly annoyed: “Gas or electric?” Now you are getting a sense of how much time I spend around my dryer: “Umm, not sure.”

There was a pause on the other end of the line, and a pit in my stomach. I was thinking, “I can’t believe I am failing a screening test for this darn appliance.” As I considered making up an answer, he broke the silence: “Well … then I guess I’ll just have to pay you a visit.”

Lesson: It is pretty hard to take good care of your dryer, or to fix it when it breaks, if you don’t know too much about it. HM groups need to get to know each other, to have an understanding of what we are made of, and how we can help each other when in need of “repair.”

Tender, Loving Care

When Fred arrived at my house, he thoroughly disarticulated the dryer into remarkably small pieces. It didn’t take long after to find the culprit. There was enough lint built up around the innards to ignite a large factory.

Feeling a little defensive about my lack of dryer maintenance, I launched into a litany of complaints about my husband. “He doesn’t believe in lint traps, thinks cleaning them is beyond a nuisance, and only resorts to the task when gray dust bunnies are bulging out of the top.” It was about this time that Fred, with years of old-fashioned Southern wisdom, pointed out to me that I was lucky to have a husband that goes near a dryer; based on one-too-many husband-complaint sessions with friends, Fred had a pretty good point.

Fred was visibly disgusted with the lack of maintenance and care of this trusted appliance, because, as he later disclosed, he doesn’t just fix dryers, he actually loves dryers, which is respectable in a strange sort of way. I felt a surge of Catholic guilt about my lack of maintenance, so I vowed to Fred to take care of my dryer with all my ability, and thanked him for a job well done.

Lesson: If you don’t regularly maintain the lint trap, it all builds up on the inside, which can ignite a fire. HM groups need to regularly participate in “maintenance” functions, to keep the group humming along without risk of combustion. Such maintenance should include evaluation of roles, responsibilities, and reimbursement structures that result in equity and longevity.

The Smart Squeeze

After a few weeks of peace and harmony in the Scheurer household, without a single school uniform being re-worn with a ketchup stain, again, the unspeakable happened. An entire load of wet laundry sat in the dryer, stuck in park, with a wetter load in the washer. I flipped the switch; nothing happened. This time I even went so far as to “pop the hood,” just to look around (not that I knew what I was looking for). Without an obvious defect glaring at me, I closed the hood and, hesitantly, called Fred.

He promptly returned, on a Saturday morning, to my dwelling, and began the disarticulation process again. But before the third screw was off, he yelled, “Aha!”

Now, I wasn’t sure if the “aha” was going to translate into a “once again, you have proven yourself incapable of maintaining a simple appliance” when he disclosed, “the belt’s broke.”

What a relief; the belt broke. Surely I had no culpability for a broken belt. Alas, the broken belt had little to do with the uncooperative dryer; the belt broke because I had overloaded the old, pitiful thing. In an attempt at efficiency, I threw in a big, sopping load of towels, at least half a dozen too many, topped off with a bath mat.

Lesson: There is only so much efficiency you can squeeze out of a hospitalist group. If you load it up too heavy, it will break.

Take Stock of Your ‘Appliance’

So you see, hospitalist groups really are a lot like dryers: hundreds of brands and model types, differing slightly in maintenance requirements and load-bearing abilities, but all sharing some common denominators: a need to be understood, a need to be maintained, and a need to not be overloaded.

So ask yourself the following questions about your group:

• Do we know what brands we have?
• Are we cleaning out our lint?
• Are we breaking some belts?

If you don’t know the answers, you should probably find out...or else call Fred.

Dr. Scheurer is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Well-designed forms of non-monetary compensation can have a greater impact on a hospitalist than providing a reward in dollars. This is true for any employee in any enterprise. It can have a greater impact than dollars in making a doctor feel appreciated and committed to the work of the organization. For example, a $100 gift certificate at a nice local restaurant can have a lot more impact and value than adding an extra $100 to the next paycheck.

A hospitalist’s salary and typical benefits (e.g. health insurance and retirement plan) must be attractive and competitive in the marketplace (obviously), but they are typically seen as entitlements, so they aren’t very effective at improving retention or motivating a doctor to perform well. Various forms of non-monetary compensation can be an effective way to achieve these things.

I should say that as I’m using the term here, non-monetary compensation includes things provided in some form other than dollars. But many forms—such as a restaurant gift certificate or tickets to a baseball game—likely will cost the practice something to provide. They also could be taxable to the doctor (i.e. should be reported on a W-2 statement), and Stark laws apply.

When discussing a citizenship bonus in my November 2011 column (see “Good Citizenship,” p. 53), I mentioned Daniel Pink’s book Drive: The Surprising Truth About What Motivates Us. In it, he argues that “Carrots and sticks are so last-century. We need to upgrade to autonomy, mastery, and purpose.” I’ll discuss forms of non-monetary compensation that fall into a modified version of Pink’s three upgrade categories.

Recognition

When is the last time a hospitalist leader or hospital executive sent a handwritten note of thanks and recognition to a hospitalist? It costs nothing, and it can be brief. Variations on this theme include awarding a plaque or trophy at a group meeting, or having an annual social event, such as a holiday party, that includes expressions of praise and gratitude for accomplishments in front of all the hospitalists and their significant others.

SHM past president Joseph Ming Wah Li, MD, SFHM, presides over his group’s annual “Hospy Awards,” a name inspired by ESPN’s ESPY Awards. Nurses, case managers, and residents vote for different awards and are asked to provide written comments about the doctor they’re voting for. Joe reads comments about both the winners and other hospitalists. The group has several additional social events each year, and photos from these are posted on the Internet.

Some hospital CEOs or other leaders periodically invite hospitalists to their homes for a dinner as a way of recognizing their work, as well as to build relationships and connectedness.

I was co-presenter in a session at HM12 in San Diego. Attendees had several terrific suggestions, including:

• Sending a note to the hospitalist’s significant other, rather than the hospitalist herself, expressing thanks for sharing her with us. Doing so is a way of acknowledging the good work of the hospitalist and the potential sacrifice of his or her family behind it. A short note of thanks with a restaurant gift certificate, so that hospitalist and a significant other can have dinner out paid for by the practice, seems like a great idea.
• Another idea that on the surface seems pretty silly, but likely has real value, is to identify a “superhero hospitalist” at some or all monthly group meetings. The group leader who brought it up does this by superimposing a photo of the doctor’s head onto a picture of a superhero like Superman and projects it during the meeting while saying something about the good work done to earn it. While silly, it has created some interest within the group regarding who the next winner will be and which superhero the honoree will be.

Promotion

Promoting a doctor into a position with greater responsibility, and perhaps a little (OK, maybe very little) prestige can be a valuable form of non-monetary compensation. A promotion could be as small as electing a doctor to serve on the hospitalist group’s own advisory committee, or representing the group at the hospital’s medical executive committee or other leadership group. More significant promotions could be having the hospitalist serve as medical director for case management or a clinical activity, such as palliative care; these positions often include additional monetary compensation.

SHM offers recognition in the form of fellowship and the opportunity for promotion to Senior Fellow in Hospital Medicine and Master of Hospital Medicine status. This can be seen as a promotion.

Professional Development

I think it is pretty tough to work an entire career devoted solely to patient care in any field, not just hospitalist practice. In June 2011 (see “Good Advice, Bad Advice,” p. 46), I wrote about the value of every hospitalist having at least a few additional professional interests and activities. A practice can encourage development of new interests and career roles, and make some available as a reward and recognition for good performance. Examples include sending your superstar doctors to SHM’s Leadership Academy, or even enroll them in a course to expand their clinical skill set, such as a procedures course or one that teaches interpretation of carotid ultrasounds or echocardiograms. An institution might find it worthwhile to reward the right doctor by paying their tuition at an executive MHA or MBA program.

It is all too easy to think that salary and benefits are the only rewards—i.e., compensation—that matter. Yet, in addition to money, all of us seek rewards in recognition, promotion, and professional development, and every practice should think deliberately about whether there are valuable opportunities in these categories.

I’d love to hear from anyone who has put in place novel and effective non-monetary compensation.

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

Well-designed forms of non-monetary compensation can have a greater impact on a hospitalist than providing a reward in dollars. This is true for any employee in any enterprise. It can have a greater impact than dollars in making a doctor feel appreciated and committed to the work of the organization. For example, a $100 gift certificate at a nice local restaurant can have a lot more impact and value than adding an extra $100 to the next paycheck.

A hospitalist’s salary and typical benefits (e.g. health insurance and retirement plan) must be attractive and competitive in the marketplace (obviously), but they are typically seen as entitlements, so they aren’t very effective at improving retention or motivating a doctor to perform well. Various forms of non-monetary compensation can be an effective way to achieve these things.

I should say that as I’m using the term here, non-monetary compensation includes things provided in some form other than dollars. But many forms—such as a restaurant gift certificate or tickets to a baseball game—likely will cost the practice something to provide. They also could be taxable to the doctor (i.e. should be reported on a W-2 statement), and Stark laws apply.

When discussing a citizenship bonus in my November 2011 column (see “Good Citizenship,” p. 53), I mentioned Daniel Pink’s book Drive: The Surprising Truth About What Motivates Us. In it, he argues that “Carrots and sticks are so last-century. We need to upgrade to autonomy, mastery, and purpose.” I’ll discuss forms of non-monetary compensation that fall into a modified version of Pink’s three upgrade categories.

Recognition

When is the last time a hospitalist leader or hospital executive sent a handwritten note of thanks and recognition to a hospitalist? It costs nothing, and it can be brief. Variations on this theme include awarding a plaque or trophy at a group meeting, or having an annual social event, such as a holiday party, that includes expressions of praise and gratitude for accomplishments in front of all the hospitalists and their significant others.

SHM past president Joseph Ming Wah Li, MD, SFHM, presides over his group’s annual “Hospy Awards,” a name inspired by ESPN’s ESPY Awards. Nurses, case managers, and residents vote for different awards and are asked to provide written comments about the doctor they’re voting for. Joe reads comments about both the winners and other hospitalists. The group has several additional social events each year, and photos from these are posted on the Internet.

Some hospital CEOs or other leaders periodically invite hospitalists to their homes for a dinner as a way of recognizing their work, as well as to build relationships and connectedness.

I was co-presenter in a session at HM12 in San Diego. Attendees had several terrific suggestions, including:

• Sending a note to the hospitalist’s significant other, rather than the hospitalist herself, expressing thanks for sharing her with us. Doing so is a way of acknowledging the good work of the hospitalist and the potential sacrifice of his or her family behind it. A short note of thanks with a restaurant gift certificate, so that hospitalist and a significant other can have dinner out paid for by the practice, seems like a great idea.
• Another idea that on the surface seems pretty silly, but likely has real value, is to identify a “superhero hospitalist” at some or all monthly group meetings. The group leader who brought it up does this by superimposing a photo of the doctor’s head onto a picture of a superhero like Superman and projects it during the meeting while saying something about the good work done to earn it. While silly, it has created some interest within the group regarding who the next winner will be and which superhero the honoree will be.

Promotion

Promoting a doctor into a position with greater responsibility, and perhaps a little (OK, maybe very little) prestige can be a valuable form of non-monetary compensation. A promotion could be as small as electing a doctor to serve on the hospitalist group’s own advisory committee, or representing the group at the hospital’s medical executive committee or other leadership group. More significant promotions could be having the hospitalist serve as medical director for case management or a clinical activity, such as palliative care; these positions often include additional monetary compensation.

SHM offers recognition in the form of fellowship and the opportunity for promotion to Senior Fellow in Hospital Medicine and Master of Hospital Medicine status. This can be seen as a promotion.

Professional Development

I think it is pretty tough to work an entire career devoted solely to patient care in any field, not just hospitalist practice. In June 2011 (see “Good Advice, Bad Advice,” p. 46), I wrote about the value of every hospitalist having at least a few additional professional interests and activities. A practice can encourage development of new interests and career roles, and make some available as a reward and recognition for good performance. Examples include sending your superstar doctors to SHM’s Leadership Academy, or even enroll them in a course to expand their clinical skill set, such as a procedures course or one that teaches interpretation of carotid ultrasounds or echocardiograms. An institution might find it worthwhile to reward the right doctor by paying their tuition at an executive MHA or MBA program.

It is all too easy to think that salary and benefits are the only rewards—i.e., compensation—that matter. Yet, in addition to money, all of us seek rewards in recognition, promotion, and professional development, and every practice should think deliberately about whether there are valuable opportunities in these categories.

I’d love to hear from anyone who has put in place novel and effective non-monetary compensation.

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

Well-designed forms of non-monetary compensation can have a greater impact on a hospitalist than providing a reward in dollars. This is true for any employee in any enterprise. It can have a greater impact than dollars in making a doctor feel appreciated and committed to the work of the organization. For example, a $100 gift certificate at a nice local restaurant can have a lot more impact and value than adding an extra $100 to the next paycheck.

A hospitalist’s salary and typical benefits (e.g. health insurance and retirement plan) must be attractive and competitive in the marketplace (obviously), but they are typically seen as entitlements, so they aren’t very effective at improving retention or motivating a doctor to perform well. Various forms of non-monetary compensation can be an effective way to achieve these things.

I should say that as I’m using the term here, non-monetary compensation includes things provided in some form other than dollars. But many forms—such as a restaurant gift certificate or tickets to a baseball game—likely will cost the practice something to provide. They also could be taxable to the doctor (i.e. should be reported on a W-2 statement), and Stark laws apply.

When discussing a citizenship bonus in my November 2011 column (see “Good Citizenship,” p. 53), I mentioned Daniel Pink’s book Drive: The Surprising Truth About What Motivates Us. In it, he argues that “Carrots and sticks are so last-century. We need to upgrade to autonomy, mastery, and purpose.” I’ll discuss forms of non-monetary compensation that fall into a modified version of Pink’s three upgrade categories.

Recognition

When is the last time a hospitalist leader or hospital executive sent a handwritten note of thanks and recognition to a hospitalist? It costs nothing, and it can be brief. Variations on this theme include awarding a plaque or trophy at a group meeting, or having an annual social event, such as a holiday party, that includes expressions of praise and gratitude for accomplishments in front of all the hospitalists and their significant others.

SHM past president Joseph Ming Wah Li, MD, SFHM, presides over his group’s annual “Hospy Awards,” a name inspired by ESPN’s ESPY Awards. Nurses, case managers, and residents vote for different awards and are asked to provide written comments about the doctor they’re voting for. Joe reads comments about both the winners and other hospitalists. The group has several additional social events each year, and photos from these are posted on the Internet.

Some hospital CEOs or other leaders periodically invite hospitalists to their homes for a dinner as a way of recognizing their work, as well as to build relationships and connectedness.

I was co-presenter in a session at HM12 in San Diego. Attendees had several terrific suggestions, including:

• Sending a note to the hospitalist’s significant other, rather than the hospitalist herself, expressing thanks for sharing her with us. Doing so is a way of acknowledging the good work of the hospitalist and the potential sacrifice of his or her family behind it. A short note of thanks with a restaurant gift certificate, so that hospitalist and a significant other can have dinner out paid for by the practice, seems like a great idea.
• Another idea that on the surface seems pretty silly, but likely has real value, is to identify a “superhero hospitalist” at some or all monthly group meetings. The group leader who brought it up does this by superimposing a photo of the doctor’s head onto a picture of a superhero like Superman and projects it during the meeting while saying something about the good work done to earn it. While silly, it has created some interest within the group regarding who the next winner will be and which superhero the honoree will be.

Promotion

Promoting a doctor into a position with greater responsibility, and perhaps a little (OK, maybe very little) prestige can be a valuable form of non-monetary compensation. A promotion could be as small as electing a doctor to serve on the hospitalist group’s own advisory committee, or representing the group at the hospital’s medical executive committee or other leadership group. More significant promotions could be having the hospitalist serve as medical director for case management or a clinical activity, such as palliative care; these positions often include additional monetary compensation.

SHM offers recognition in the form of fellowship and the opportunity for promotion to Senior Fellow in Hospital Medicine and Master of Hospital Medicine status. This can be seen as a promotion.

Professional Development

I think it is pretty tough to work an entire career devoted solely to patient care in any field, not just hospitalist practice. In June 2011 (see “Good Advice, Bad Advice,” p. 46), I wrote about the value of every hospitalist having at least a few additional professional interests and activities. A practice can encourage development of new interests and career roles, and make some available as a reward and recognition for good performance. Examples include sending your superstar doctors to SHM’s Leadership Academy, or even enroll them in a course to expand their clinical skill set, such as a procedures course or one that teaches interpretation of carotid ultrasounds or echocardiograms. An institution might find it worthwhile to reward the right doctor by paying their tuition at an executive MHA or MBA program.

It is all too easy to think that salary and benefits are the only rewards—i.e., compensation—that matter. Yet, in addition to money, all of us seek rewards in recognition, promotion, and professional development, and every practice should think deliberately about whether there are valuable opportunities in these categories.

I’d love to hear from anyone who has put in place novel and effective non-monetary compensation.

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

I am decidedly anti-politics. The entire process seems fatally flawed. The vast majority of the public votes based on one or two emotional interests, such as religion or personal finances. The candidates’ responses are calculated, based on the millions of dollars they receive from competing interest groups and evidence-based analysis of what will garner the most votes. So for me at this time of year, watching debates and TV coverage of primaries is akin to watching an MTV reality show—lots of drama, little substance.

But there is one election (of sorts) this year that gives me hope: Our input has been solicited by the Strategic Planning (STP) Committee to help sort through the issue of certification in pediatric hospital medicine. What is potentially at stake here is how we define ourselves as a field. At one end is the traditional, three-year fellowship with certification as a subspecialty. At the other end is no change, or the status quo. In between are myriad options, each with unique pros and cons. It is all summarized at the STP blog (http://stpcommittee.blogspot.com), which allows for input.

This is a unique opportunity, as pediatric HM is at a crossroads. The STP Committee states that this solicitation of public comment is different from processes that other fields (pediatric emergency medicine, child abuse, adult hospital medicine) have used, and it will allow for more engagement of the pediatric hospitalist community at large. I agree. And I heartily endorse an open forum for this process.

What happens after this is somewhat less clear, but it involves synthesis of all of the input and presentation to the Joint Council of Pediatric Hospital Medicine (JCPHM). In addition, the American Pediatric Association (APA), the American Academy of Pediatrics (AAP), and SHM representatives will solicit feedback from their leadership and membership. A minor drawback of this process is the fact that the JCPHM remains a somewhat mythical body to date, as it has not been publicly defined to my knowledge. But this will be the body that makes the final decision.

The Candidates

OK, enough of the sausage-making (“laws are like sausages: It is best not to see them being made”) and on to the actual candidates. I suppose we should begin with the “incumbent”—the status quo. I will not rehash the pros and cons that have been meticulously laid out by the STP Committee on the website. But I will add that this candidate has the benefit of being well-known and is the least complicated option. Unfortunately, it’s also the least sexy option, which I’m told is actually a factor in elections. Given the number of alternatives that the committee has laid out, I’m not going with this one, simply because there has to be a better one out there.

I also immediately discount the option on the other end of the spectrum: a full three-year fellowship (the current standard for subspecialists). We’re all familiar with the details of this option, but the year of research is, on average, a bigger waste of time than college calculus. I remember a lot of fellows who didn’t care about research; they were sleeping next to me in the clinical research classes, ones that I was taking in my spare time. They completed projects to get through the fellowship, and that was it for “research” in their careers. Now, I can’t exclude the fact that they learned something from those projects, but the American Board of Pediatrics (ABP) clearly states that the “rationale for including a requirement for participation in scholarly activity flows from the belief that the principal goal of fellowship training should be the development of future academic pediatricians.”1 Practice in a community hospital is quite different from that of an academic pediatrician.

(This is not to say that we do not need a pipeline of future academic leaders, an absolute necessity for our young field. However, if we are to decide certification options for everyone, I think we should focus on a set of minimum requirements and have additional options, or tracks, for academicians. Thus, I would reframe the debate to focus on what every hospitalist needs.)

What is really needed to train effective pediatric hospitalists? I think we begin by acknowledging that additional clinical training is a priority for several reasons:

• Pediatric residents are receiving less and less inpatient training;
• Our patients are increasingly complex; and
• The hospital is a unique and complicated system within which to practice.

I was trained in the good ol’ days, before duty hours, and I was still pretty dumb when I started as an attending. While I don’t think it’s difficult for new grads to learn on the job, once you pay someone a full salary and give them billing as a full-fledged attending, you lose a lot of leeway—on both sides—to structure their education.

Some standard of quality and safety training should be included in this minimum requirement. One byproduct of the quality movement in medicine is that we now clearly understand that hospitals are complex systems with many moving parts. Interacting in that system, and providing safe and effective care within those confines, requires a certain set of knowledge, attitudes, and skills—particularly if we are to be leaders in hospital practice. It is no longer sufficient to be just a hospital-based doctor with no extramural involvement in improving the system. Strategically, this would be of value to both hospital administrators and academic institutions, our primary funding streams.

The Endorsement

So I vote for some set of minimum requirements. And I think that has to be the focus of our initial discussion. Once those are decided, the immediate next issue should be whether this is implemented as a fellowship or through focused practice. Here, I lean towards the former, as I think that a fellowship allows us to better control the quality of that training. The final issue is which option to choose, but I think that becomes a formality once minimum requirements are decided; in many instances, there may be more than one option that works.

So do your part, and contribute to the discussion. But don’t just pick an option. Describe what you think hospitalists of tomorrow need when they start their careers. And enjoy this refreshing process, one without the irrationalities of politics and something that we can all buy into for the future of pediatric HM.

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

Reference

1. American Board of Pediatrics. Training requirements for subspecialty certification. American Board of Pediatrics website. Available at: https://www.abp.org/abpwebsite/publicat/trainingrequirements.pdf. Accessed May 1, 2012.

I am decidedly anti-politics. The entire process seems fatally flawed. The vast majority of the public votes based on one or two emotional interests, such as religion or personal finances. The candidates’ responses are calculated, based on the millions of dollars they receive from competing interest groups and evidence-based analysis of what will garner the most votes. So for me at this time of year, watching debates and TV coverage of primaries is akin to watching an MTV reality show—lots of drama, little substance.

But there is one election (of sorts) this year that gives me hope: Our input has been solicited by the Strategic Planning (STP) Committee to help sort through the issue of certification in pediatric hospital medicine. What is potentially at stake here is how we define ourselves as a field. At one end is the traditional, three-year fellowship with certification as a subspecialty. At the other end is no change, or the status quo. In between are myriad options, each with unique pros and cons. It is all summarized at the STP blog (http://stpcommittee.blogspot.com), which allows for input.

This is a unique opportunity, as pediatric HM is at a crossroads. The STP Committee states that this solicitation of public comment is different from processes that other fields (pediatric emergency medicine, child abuse, adult hospital medicine) have used, and it will allow for more engagement of the pediatric hospitalist community at large. I agree. And I heartily endorse an open forum for this process.

What happens after this is somewhat less clear, but it involves synthesis of all of the input and presentation to the Joint Council of Pediatric Hospital Medicine (JCPHM). In addition, the American Pediatric Association (APA), the American Academy of Pediatrics (AAP), and SHM representatives will solicit feedback from their leadership and membership. A minor drawback of this process is the fact that the JCPHM remains a somewhat mythical body to date, as it has not been publicly defined to my knowledge. But this will be the body that makes the final decision.

The Candidates

OK, enough of the sausage-making (“laws are like sausages: It is best not to see them being made”) and on to the actual candidates. I suppose we should begin with the “incumbent”—the status quo. I will not rehash the pros and cons that have been meticulously laid out by the STP Committee on the website. But I will add that this candidate has the benefit of being well-known and is the least complicated option. Unfortunately, it’s also the least sexy option, which I’m told is actually a factor in elections. Given the number of alternatives that the committee has laid out, I’m not going with this one, simply because there has to be a better one out there.

I also immediately discount the option on the other end of the spectrum: a full three-year fellowship (the current standard for subspecialists). We’re all familiar with the details of this option, but the year of research is, on average, a bigger waste of time than college calculus. I remember a lot of fellows who didn’t care about research; they were sleeping next to me in the clinical research classes, ones that I was taking in my spare time. They completed projects to get through the fellowship, and that was it for “research” in their careers. Now, I can’t exclude the fact that they learned something from those projects, but the American Board of Pediatrics (ABP) clearly states that the “rationale for including a requirement for participation in scholarly activity flows from the belief that the principal goal of fellowship training should be the development of future academic pediatricians.”1 Practice in a community hospital is quite different from that of an academic pediatrician.

(This is not to say that we do not need a pipeline of future academic leaders, an absolute necessity for our young field. However, if we are to decide certification options for everyone, I think we should focus on a set of minimum requirements and have additional options, or tracks, for academicians. Thus, I would reframe the debate to focus on what every hospitalist needs.)

What is really needed to train effective pediatric hospitalists? I think we begin by acknowledging that additional clinical training is a priority for several reasons:

• Pediatric residents are receiving less and less inpatient training;
• Our patients are increasingly complex; and
• The hospital is a unique and complicated system within which to practice.

I was trained in the good ol’ days, before duty hours, and I was still pretty dumb when I started as an attending. While I don’t think it’s difficult for new grads to learn on the job, once you pay someone a full salary and give them billing as a full-fledged attending, you lose a lot of leeway—on both sides—to structure their education.

Some standard of quality and safety training should be included in this minimum requirement. One byproduct of the quality movement in medicine is that we now clearly understand that hospitals are complex systems with many moving parts. Interacting in that system, and providing safe and effective care within those confines, requires a certain set of knowledge, attitudes, and skills—particularly if we are to be leaders in hospital practice. It is no longer sufficient to be just a hospital-based doctor with no extramural involvement in improving the system. Strategically, this would be of value to both hospital administrators and academic institutions, our primary funding streams.

The Endorsement

So I vote for some set of minimum requirements. And I think that has to be the focus of our initial discussion. Once those are decided, the immediate next issue should be whether this is implemented as a fellowship or through focused practice. Here, I lean towards the former, as I think that a fellowship allows us to better control the quality of that training. The final issue is which option to choose, but I think that becomes a formality once minimum requirements are decided; in many instances, there may be more than one option that works.

So do your part, and contribute to the discussion. But don’t just pick an option. Describe what you think hospitalists of tomorrow need when they start their careers. And enjoy this refreshing process, one without the irrationalities of politics and something that we can all buy into for the future of pediatric HM.

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

Reference

1. American Board of Pediatrics. Training requirements for subspecialty certification. American Board of Pediatrics website. Available at: https://www.abp.org/abpwebsite/publicat/trainingrequirements.pdf. Accessed May 1, 2012.

I am decidedly anti-politics. The entire process seems fatally flawed. The vast majority of the public votes based on one or two emotional interests, such as religion or personal finances. The candidates’ responses are calculated, based on the millions of dollars they receive from competing interest groups and evidence-based analysis of what will garner the most votes. So for me at this time of year, watching debates and TV coverage of primaries is akin to watching an MTV reality show—lots of drama, little substance.

But there is one election (of sorts) this year that gives me hope: Our input has been solicited by the Strategic Planning (STP) Committee to help sort through the issue of certification in pediatric hospital medicine. What is potentially at stake here is how we define ourselves as a field. At one end is the traditional, three-year fellowship with certification as a subspecialty. At the other end is no change, or the status quo. In between are myriad options, each with unique pros and cons. It is all summarized at the STP blog (http://stpcommittee.blogspot.com), which allows for input.

This is a unique opportunity, as pediatric HM is at a crossroads. The STP Committee states that this solicitation of public comment is different from processes that other fields (pediatric emergency medicine, child abuse, adult hospital medicine) have used, and it will allow for more engagement of the pediatric hospitalist community at large. I agree. And I heartily endorse an open forum for this process.

What happens after this is somewhat less clear, but it involves synthesis of all of the input and presentation to the Joint Council of Pediatric Hospital Medicine (JCPHM). In addition, the American Pediatric Association (APA), the American Academy of Pediatrics (AAP), and SHM representatives will solicit feedback from their leadership and membership. A minor drawback of this process is the fact that the JCPHM remains a somewhat mythical body to date, as it has not been publicly defined to my knowledge. But this will be the body that makes the final decision.

The Candidates

OK, enough of the sausage-making (“laws are like sausages: It is best not to see them being made”) and on to the actual candidates. I suppose we should begin with the “incumbent”—the status quo. I will not rehash the pros and cons that have been meticulously laid out by the STP Committee on the website. But I will add that this candidate has the benefit of being well-known and is the least complicated option. Unfortunately, it’s also the least sexy option, which I’m told is actually a factor in elections. Given the number of alternatives that the committee has laid out, I’m not going with this one, simply because there has to be a better one out there.

I also immediately discount the option on the other end of the spectrum: a full three-year fellowship (the current standard for subspecialists). We’re all familiar with the details of this option, but the year of research is, on average, a bigger waste of time than college calculus. I remember a lot of fellows who didn’t care about research; they were sleeping next to me in the clinical research classes, ones that I was taking in my spare time. They completed projects to get through the fellowship, and that was it for “research” in their careers. Now, I can’t exclude the fact that they learned something from those projects, but the American Board of Pediatrics (ABP) clearly states that the “rationale for including a requirement for participation in scholarly activity flows from the belief that the principal goal of fellowship training should be the development of future academic pediatricians.”1 Practice in a community hospital is quite different from that of an academic pediatrician.

(This is not to say that we do not need a pipeline of future academic leaders, an absolute necessity for our young field. However, if we are to decide certification options for everyone, I think we should focus on a set of minimum requirements and have additional options, or tracks, for academicians. Thus, I would reframe the debate to focus on what every hospitalist needs.)

What is really needed to train effective pediatric hospitalists? I think we begin by acknowledging that additional clinical training is a priority for several reasons:

• Pediatric residents are receiving less and less inpatient training;
• Our patients are increasingly complex; and
• The hospital is a unique and complicated system within which to practice.

I was trained in the good ol’ days, before duty hours, and I was still pretty dumb when I started as an attending. While I don’t think it’s difficult for new grads to learn on the job, once you pay someone a full salary and give them billing as a full-fledged attending, you lose a lot of leeway—on both sides—to structure their education.

Some standard of quality and safety training should be included in this minimum requirement. One byproduct of the quality movement in medicine is that we now clearly understand that hospitals are complex systems with many moving parts. Interacting in that system, and providing safe and effective care within those confines, requires a certain set of knowledge, attitudes, and skills—particularly if we are to be leaders in hospital practice. It is no longer sufficient to be just a hospital-based doctor with no extramural involvement in improving the system. Strategically, this would be of value to both hospital administrators and academic institutions, our primary funding streams.

The Endorsement

So I vote for some set of minimum requirements. And I think that has to be the focus of our initial discussion. Once those are decided, the immediate next issue should be whether this is implemented as a fellowship or through focused practice. Here, I lean towards the former, as I think that a fellowship allows us to better control the quality of that training. The final issue is which option to choose, but I think that becomes a formality once minimum requirements are decided; in many instances, there may be more than one option that works.

So do your part, and contribute to the discussion. But don’t just pick an option. Describe what you think hospitalists of tomorrow need when they start their careers. And enjoy this refreshing process, one without the irrationalities of politics and something that we can all buy into for the future of pediatric HM.

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

Reference

1. American Board of Pediatrics. Training requirements for subspecialty certification. American Board of Pediatrics website. Available at: https://www.abp.org/abpwebsite/publicat/trainingrequirements.pdf. Accessed May 1, 2012.

Change Happens—Make Sure You Are Prepared

My hospitalist group is imploding. What do I do?

—Concerned in Georgia

Dr. Hospitalist responds:

Well, if there is one thing HM lacks, it’s certainty. When I first started out as a hospitalist oh-so-many years ago (it was the 1990s), our field was nascent, and we all figured we’d do this for a year or two, then be out of a job. Once it became clear that the work was here to stay, the day-to-day unpredictability of the job came to the fore. How would we ever get to level staffing? How was it possible to get 20 admissions one day and two the next? Why would you have a unit full of raging, naked, withdrawing alcoholics one week, and the next, your service would be sweet grandmas who broke their hips? I mean, variety can be delightful, but yeesh, this was nuts.

Fast-forward to 2012, and HM is here to stay. The volumes may vary, but the work isn’t going away—and primary-care physicians (PCPs) aren’t coming back to make rounds. The uncertainty still exists, but it centers more around insurance payments (27% pay cut narrowly avoided!), hospital contracts, and employment models. This scenario is by no means unique to hospitalists. Just look at the wrenching changes that the cardiologists have gone through in the past few years with the cut in outpatient procedure payments. For better or for worse, even in HM Year 15+, change is the only constant.

Your group is imploding. There are a few scenarios there:

• Maybe you’ve been mismanaged (been there);
• Perhaps the hospital decided not to renew your contract (been there, too);
• Your group was acquired by a larger group; or
• Another local group just took a big chunk of your business, and that means staffing cuts.

My point is, whether all or none of these situations have ever happened to you as a hospitalist, they all exist. I just don’t think you can safely look at any physician job in 2012 and say, “Yeah, this job will be good for the next 10 years.” We have way too much uncertainty in the business model. This is not to say that the profession is going to deteriorate, but that you need to be prepared for ongoing evolution.

If luck is the product of preparation and opportunity, then disaster comes from complacency and assumption. So keep your CV updated. No need to broadcast it; just pull up the file once a year and make the needed changes. Expand your skill set. FCCS certification might make sense if you do a lot of ICU work. Document your committee experience (don’t tell me your hospital committees are all full).

Apply for Fellow in Hospital Medicine designation (www.hospitalmedicine.org/fellow). Maintain your certification through the Focused Practice in HM pathway (www.abim.org).

Maintain your connections, whether it’s through local chapter meetings and CME or attending SHM’s annual meeting (www.hospitalmedicine.org/events).

Know the work environment in your community: Which job would you take if your current one went away?

Even if you are reading this thinking, “There is just no way this kind of change could happen to my group,” trust me, it can. And quickly. You should expect change, and know what your options are when it comes along.

Change Happens—Make Sure You Are Prepared

My hospitalist group is imploding. What do I do?

—Concerned in Georgia

Dr. Hospitalist responds:

Well, if there is one thing HM lacks, it’s certainty. When I first started out as a hospitalist oh-so-many years ago (it was the 1990s), our field was nascent, and we all figured we’d do this for a year or two, then be out of a job. Once it became clear that the work was here to stay, the day-to-day unpredictability of the job came to the fore. How would we ever get to level staffing? How was it possible to get 20 admissions one day and two the next? Why would you have a unit full of raging, naked, withdrawing alcoholics one week, and the next, your service would be sweet grandmas who broke their hips? I mean, variety can be delightful, but yeesh, this was nuts.

Fast-forward to 2012, and HM is here to stay. The volumes may vary, but the work isn’t going away—and primary-care physicians (PCPs) aren’t coming back to make rounds. The uncertainty still exists, but it centers more around insurance payments (27% pay cut narrowly avoided!), hospital contracts, and employment models. This scenario is by no means unique to hospitalists. Just look at the wrenching changes that the cardiologists have gone through in the past few years with the cut in outpatient procedure payments. For better or for worse, even in HM Year 15+, change is the only constant.

Your group is imploding. There are a few scenarios there:

• Maybe you’ve been mismanaged (been there);
• Perhaps the hospital decided not to renew your contract (been there, too);
• Your group was acquired by a larger group; or
• Another local group just took a big chunk of your business, and that means staffing cuts.

My point is, whether all or none of these situations have ever happened to you as a hospitalist, they all exist. I just don’t think you can safely look at any physician job in 2012 and say, “Yeah, this job will be good for the next 10 years.” We have way too much uncertainty in the business model. This is not to say that the profession is going to deteriorate, but that you need to be prepared for ongoing evolution.

If luck is the product of preparation and opportunity, then disaster comes from complacency and assumption. So keep your CV updated. No need to broadcast it; just pull up the file once a year and make the needed changes. Expand your skill set. FCCS certification might make sense if you do a lot of ICU work. Document your committee experience (don’t tell me your hospital committees are all full).

Apply for Fellow in Hospital Medicine designation (www.hospitalmedicine.org/fellow). Maintain your certification through the Focused Practice in HM pathway (www.abim.org).

Maintain your connections, whether it’s through local chapter meetings and CME or attending SHM’s annual meeting (www.hospitalmedicine.org/events).

Know the work environment in your community: Which job would you take if your current one went away?

Even if you are reading this thinking, “There is just no way this kind of change could happen to my group,” trust me, it can. And quickly. You should expect change, and know what your options are when it comes along.

Change Happens—Make Sure You Are Prepared

My hospitalist group is imploding. What do I do?

—Concerned in Georgia

Dr. Hospitalist responds:

Well, if there is one thing HM lacks, it’s certainty. When I first started out as a hospitalist oh-so-many years ago (it was the 1990s), our field was nascent, and we all figured we’d do this for a year or two, then be out of a job. Once it became clear that the work was here to stay, the day-to-day unpredictability of the job came to the fore. How would we ever get to level staffing? How was it possible to get 20 admissions one day and two the next? Why would you have a unit full of raging, naked, withdrawing alcoholics one week, and the next, your service would be sweet grandmas who broke their hips? I mean, variety can be delightful, but yeesh, this was nuts.

Fast-forward to 2012, and HM is here to stay. The volumes may vary, but the work isn’t going away—and primary-care physicians (PCPs) aren’t coming back to make rounds. The uncertainty still exists, but it centers more around insurance payments (27% pay cut narrowly avoided!), hospital contracts, and employment models. This scenario is by no means unique to hospitalists. Just look at the wrenching changes that the cardiologists have gone through in the past few years with the cut in outpatient procedure payments. For better or for worse, even in HM Year 15+, change is the only constant.

Your group is imploding. There are a few scenarios there:

• Maybe you’ve been mismanaged (been there);
• Perhaps the hospital decided not to renew your contract (been there, too);
• Your group was acquired by a larger group; or
• Another local group just took a big chunk of your business, and that means staffing cuts.

My point is, whether all or none of these situations have ever happened to you as a hospitalist, they all exist. I just don’t think you can safely look at any physician job in 2012 and say, “Yeah, this job will be good for the next 10 years.” We have way too much uncertainty in the business model. This is not to say that the profession is going to deteriorate, but that you need to be prepared for ongoing evolution.

If luck is the product of preparation and opportunity, then disaster comes from complacency and assumption. So keep your CV updated. No need to broadcast it; just pull up the file once a year and make the needed changes. Expand your skill set. FCCS certification might make sense if you do a lot of ICU work. Document your committee experience (don’t tell me your hospital committees are all full).

Apply for Fellow in Hospital Medicine designation (www.hospitalmedicine.org/fellow). Maintain your certification through the Focused Practice in HM pathway (www.abim.org).

Maintain your connections, whether it’s through local chapter meetings and CME or attending SHM’s annual meeting (www.hospitalmedicine.org/events).

Know the work environment in your community: Which job would you take if your current one went away?

Even if you are reading this thinking, “There is just no way this kind of change could happen to my group,” trust me, it can. And quickly. You should expect change, and know what your options are when it comes along.

According to a CMS statement regarding part of President Obama’s “commitment to reducing regulatory burden,” Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to “postpone the date” by which certain healthcare entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).¹

The final rule adopting ICD-10 as a standard was published in January 2009; it set a compliance date of Oct. 1, 2013 (a two-year delay from the 2008 proposed rule). HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our healthcare system,” Sebelius said in the statement. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to re-examine the pace at which HHS and the nation implement these important improvements to our healthcare system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our healthcare data with that of the rest of the world, much of which has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

All that said, do not postpone any activities toward ICD-10 implementation until further clarification comes from CMS.

—Carol Pohlig

Reference

1. Centers for Medicare & Medicaid Services. Press Releases: HHS Announces Intent to Delay ICD-10 Compliance Date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4274&intNumPerPage=30&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date. Accessed March 1, 2012.

According to a CMS statement regarding part of President Obama’s “commitment to reducing regulatory burden,” Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to “postpone the date” by which certain healthcare entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).¹

The final rule adopting ICD-10 as a standard was published in January 2009; it set a compliance date of Oct. 1, 2013 (a two-year delay from the 2008 proposed rule). HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our healthcare system,” Sebelius said in the statement. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to re-examine the pace at which HHS and the nation implement these important improvements to our healthcare system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our healthcare data with that of the rest of the world, much of which has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

All that said, do not postpone any activities toward ICD-10 implementation until further clarification comes from CMS.

—Carol Pohlig

Reference

1. Centers for Medicare & Medicaid Services. Press Releases: HHS Announces Intent to Delay ICD-10 Compliance Date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4274&intNumPerPage=30&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date. Accessed March 1, 2012.

According to a CMS statement regarding part of President Obama’s “commitment to reducing regulatory burden,” Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to “postpone the date” by which certain healthcare entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).¹

The final rule adopting ICD-10 as a standard was published in January 2009; it set a compliance date of Oct. 1, 2013 (a two-year delay from the 2008 proposed rule). HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our healthcare system,” Sebelius said in the statement. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to re-examine the pace at which HHS and the nation implement these important improvements to our healthcare system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our healthcare data with that of the rest of the world, much of which has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

All that said, do not postpone any activities toward ICD-10 implementation until further clarification comes from CMS.

—Carol Pohlig

Reference

1. Centers for Medicare & Medicaid Services. Press Releases: HHS Announces Intent to Delay ICD-10 Compliance Date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4274&intNumPerPage=30&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date. Accessed March 1, 2012.

Aggressive medical management: thumbs up

Among stroke patients with intracranial stenosis, or the narrowing of arteries within the brain, researchers found that aggressive medical therapy and attention to risk factors outperformed a combination of drugs and percutaneous transluminal angioplasty and stenting (PTAS) in preventing stroke recurrence.11 The immediate conclusions might apply to a specific condition and be due in part to a tricky surgical stenting procedure, but experts including Dr. Likosky say it’s also indicative of the power of medical management when done appropriately. Doctors can readily adopt core elements of this therapeutic intervention, including adding clopidogrel to aspirin for the first three months, and helping patients lower their blood pressure and cholesterol levels.

Neuroimaging: thumbs up

Advanced imaging techniques like diffusion-weighted MRI (which uses the movement of water as a lens to produce a detailed map of stroke-damaged brain tissues and vessels) are helping doctors determine the best course of therapy. Evidence of a salvageable ischemic brain, Dr. Jensen says, can help make the case for interarterial removal of the obstruction. And finer resolution can help differentiate between a transient ischemic attack (TIA) and a true stroke.

Neuroprotective agents: thumbs down

Researchers have examined the potential for a range of medications to limit the amount of neurological damage after a stroke. So far, at least, none have proven to be very effective. “We just haven’t found the magic bullet,” Dr. Jensen says. “Of course, that would be the most wonderful thing in the world because you could put them in people’s houses and say, ‘If you think you’re having a stroke, start taking these pills,’ but we’re just not there yet.”

“Stent on a stick”: thumbs up

The standard FDA-approved mechanical clot remover, a helical-shaped device called the Merci Retriever, acts like a corkscrew to spear and dislodge clots, while a machine known as Penumbra does its job through suction. After showing promise in Europe, two next-generation stent retrievers, the Trevo and the Solitaire, could give the established techniques a run for their money in the U.S.

At February’s International Stroke Conference in New Orleans, researchers reported that the Solitaire (sometimes called a concentric retriever, or a “stent on a stick”) significantly outperformed the Merci in several measures of patient outcomes. The randomized, controlled SWIFT clinical trial, in fact, ended earlier than planned because the results were so promising. Clinicians recorded a three-month mortality rate of 17.2% for patients treated with Solitaire, compared with a 38.2% rate among Merci-treated patients. In addition, the trial recorded good mental and motor functions among 58.2% of Solitaire patients at three months, but only among 33.3% of the Merci cohort. At the same conference, researchers reported that a prospective European trial of the Trevo system yielded similarly encouraging results.

Aggressive medical management: thumbs up

Among stroke patients with intracranial stenosis, or the narrowing of arteries within the brain, researchers found that aggressive medical therapy and attention to risk factors outperformed a combination of drugs and percutaneous transluminal angioplasty and stenting (PTAS) in preventing stroke recurrence.11 The immediate conclusions might apply to a specific condition and be due in part to a tricky surgical stenting procedure, but experts including Dr. Likosky say it’s also indicative of the power of medical management when done appropriately. Doctors can readily adopt core elements of this therapeutic intervention, including adding clopidogrel to aspirin for the first three months, and helping patients lower their blood pressure and cholesterol levels.

Neuroimaging: thumbs up

Advanced imaging techniques like diffusion-weighted MRI (which uses the movement of water as a lens to produce a detailed map of stroke-damaged brain tissues and vessels) are helping doctors determine the best course of therapy. Evidence of a salvageable ischemic brain, Dr. Jensen says, can help make the case for interarterial removal of the obstruction. And finer resolution can help differentiate between a transient ischemic attack (TIA) and a true stroke.

Neuroprotective agents: thumbs down

Researchers have examined the potential for a range of medications to limit the amount of neurological damage after a stroke. So far, at least, none have proven to be very effective. “We just haven’t found the magic bullet,” Dr. Jensen says. “Of course, that would be the most wonderful thing in the world because you could put them in people’s houses and say, ‘If you think you’re having a stroke, start taking these pills,’ but we’re just not there yet.”

“Stent on a stick”: thumbs up

The standard FDA-approved mechanical clot remover, a helical-shaped device called the Merci Retriever, acts like a corkscrew to spear and dislodge clots, while a machine known as Penumbra does its job through suction. After showing promise in Europe, two next-generation stent retrievers, the Trevo and the Solitaire, could give the established techniques a run for their money in the U.S.

At February’s International Stroke Conference in New Orleans, researchers reported that the Solitaire (sometimes called a concentric retriever, or a “stent on a stick”) significantly outperformed the Merci in several measures of patient outcomes. The randomized, controlled SWIFT clinical trial, in fact, ended earlier than planned because the results were so promising. Clinicians recorded a three-month mortality rate of 17.2% for patients treated with Solitaire, compared with a 38.2% rate among Merci-treated patients. In addition, the trial recorded good mental and motor functions among 58.2% of Solitaire patients at three months, but only among 33.3% of the Merci cohort. At the same conference, researchers reported that a prospective European trial of the Trevo system yielded similarly encouraging results.

Aggressive medical management: thumbs up

Among stroke patients with intracranial stenosis, or the narrowing of arteries within the brain, researchers found that aggressive medical therapy and attention to risk factors outperformed a combination of drugs and percutaneous transluminal angioplasty and stenting (PTAS) in preventing stroke recurrence.11 The immediate conclusions might apply to a specific condition and be due in part to a tricky surgical stenting procedure, but experts including Dr. Likosky say it’s also indicative of the power of medical management when done appropriately. Doctors can readily adopt core elements of this therapeutic intervention, including adding clopidogrel to aspirin for the first three months, and helping patients lower their blood pressure and cholesterol levels.

Neuroimaging: thumbs up

Advanced imaging techniques like diffusion-weighted MRI (which uses the movement of water as a lens to produce a detailed map of stroke-damaged brain tissues and vessels) are helping doctors determine the best course of therapy. Evidence of a salvageable ischemic brain, Dr. Jensen says, can help make the case for interarterial removal of the obstruction. And finer resolution can help differentiate between a transient ischemic attack (TIA) and a true stroke.

Neuroprotective agents: thumbs down

Researchers have examined the potential for a range of medications to limit the amount of neurological damage after a stroke. So far, at least, none have proven to be very effective. “We just haven’t found the magic bullet,” Dr. Jensen says. “Of course, that would be the most wonderful thing in the world because you could put them in people’s houses and say, ‘If you think you’re having a stroke, start taking these pills,’ but we’re just not there yet.”

“Stent on a stick”: thumbs up

The standard FDA-approved mechanical clot remover, a helical-shaped device called the Merci Retriever, acts like a corkscrew to spear and dislodge clots, while a machine known as Penumbra does its job through suction. After showing promise in Europe, two next-generation stent retrievers, the Trevo and the Solitaire, could give the established techniques a run for their money in the U.S.

At February’s International Stroke Conference in New Orleans, researchers reported that the Solitaire (sometimes called a concentric retriever, or a “stent on a stick”) significantly outperformed the Merci in several measures of patient outcomes. The randomized, controlled SWIFT clinical trial, in fact, ended earlier than planned because the results were so promising. Clinicians recorded a three-month mortality rate of 17.2% for patients treated with Solitaire, compared with a 38.2% rate among Merci-treated patients. In addition, the trial recorded good mental and motor functions among 58.2% of Solitaire patients at three months, but only among 33.3% of the Merci cohort. At the same conference, researchers reported that a prospective European trial of the Trevo system yielded similarly encouraging results.

A year ago in March, I looked my father in the eyes for the last time as he mouthed the words "help me" from his ICU bed. But despite being surrounded by teams of medical personnel and the latest healthcare technology, I felt utterly powerless to make a clear decision—and unclear to whom to turn for sound advice.

After 30 days of care in a well-known teaching hospital in the Northeast, my father was about to succumb to Stage 4 lung cancer, a tumor invading his spine. Moments before his plea, the ICU team had conducted a breathing test that apparently went awry—beginning the trial while my mother and I were downstairs receiving the latest round of conflicting information from a pair of doctors debating his outlook for discharge, physical rehabilitation, and hospice care. They casually informed us that a breathing test was about to occur; we rushed back to my father's side to learn the unfortunate outcome.

Prior to the episode that led to his being moved to the ICU, my father had been residing in a room directly across from a small hospitalist oncology office. What ensued was dizzying to behold: an endless parade of consultations; a narrowly averted million-dollar-plus spinal surgery in the wee hours; a too-zealous resident's further injuring of my father's right leg, which had already been compromised by a tumor degrading the femur.

My mother, my wife, and I struggled to maintain Dad's always-indomitable spirit while parsing the barrage of input regarding his potential for quality of life outside the hospital. We sat in numerous meetings, often with a pair of doctors espousing diametrically opposed outlooks. We tried to keep track of whom we were speaking with and who was in charge at any given moment; the lists we kept looked like the roster of a sports team, amply covered in scribbled-out names, phone numbers—and question marks.

It was only after my father tried feebly to speak his last words to me that the doctor who'd appeared to be most in charge pulled me aside at the door of the ICU. My mother and I hemmed and hawed in trying to decide whether to accede to another round of heroic measures. I was surprised by the somewhat terse tone of voice this senior physician used in dissuading us from allowing further life-extending efforts. I would have welcomed such honesty wholeheartedly far earlier in the process.

One of the value propositions hospitalists tout to their employers and patients is their expertise in coordinating care and facilitating communication among caregivers. Of course, there are nearly as many methods for doing so as there are hospitalist teams.

As the medical process grows more complex and specialized, with more "stakeholders" weighing in on the conversation, the hospitalist's role in taking charge of and energetically managing the flow of information for the benefit of beleaguered kin is more vital than ever. I can't speak for all loved ones who must witness the passage of a parent, a child, or a spouse, but for me, a hospitalist's firm hand would have made a world of difference in how we navigated this inevitable event.

Geoff Giordano was editor of The Hospitalist from 2007 to 2008. His father, Thomas, a lifelong journalist, wrote several articles for the magazine during that period.

A year ago in March, I looked my father in the eyes for the last time as he mouthed the words "help me" from his ICU bed. But despite being surrounded by teams of medical personnel and the latest healthcare technology, I felt utterly powerless to make a clear decision—and unclear to whom to turn for sound advice.

After 30 days of care in a well-known teaching hospital in the Northeast, my father was about to succumb to Stage 4 lung cancer, a tumor invading his spine. Moments before his plea, the ICU team had conducted a breathing test that apparently went awry—beginning the trial while my mother and I were downstairs receiving the latest round of conflicting information from a pair of doctors debating his outlook for discharge, physical rehabilitation, and hospice care. They casually informed us that a breathing test was about to occur; we rushed back to my father's side to learn the unfortunate outcome.

Prior to the episode that led to his being moved to the ICU, my father had been residing in a room directly across from a small hospitalist oncology office. What ensued was dizzying to behold: an endless parade of consultations; a narrowly averted million-dollar-plus spinal surgery in the wee hours; a too-zealous resident's further injuring of my father's right leg, which had already been compromised by a tumor degrading the femur.

My mother, my wife, and I struggled to maintain Dad's always-indomitable spirit while parsing the barrage of input regarding his potential for quality of life outside the hospital. We sat in numerous meetings, often with a pair of doctors espousing diametrically opposed outlooks. We tried to keep track of whom we were speaking with and who was in charge at any given moment; the lists we kept looked like the roster of a sports team, amply covered in scribbled-out names, phone numbers—and question marks.

It was only after my father tried feebly to speak his last words to me that the doctor who'd appeared to be most in charge pulled me aside at the door of the ICU. My mother and I hemmed and hawed in trying to decide whether to accede to another round of heroic measures. I was surprised by the somewhat terse tone of voice this senior physician used in dissuading us from allowing further life-extending efforts. I would have welcomed such honesty wholeheartedly far earlier in the process.

One of the value propositions hospitalists tout to their employers and patients is their expertise in coordinating care and facilitating communication among caregivers. Of course, there are nearly as many methods for doing so as there are hospitalist teams.

As the medical process grows more complex and specialized, with more "stakeholders" weighing in on the conversation, the hospitalist's role in taking charge of and energetically managing the flow of information for the benefit of beleaguered kin is more vital than ever. I can't speak for all loved ones who must witness the passage of a parent, a child, or a spouse, but for me, a hospitalist's firm hand would have made a world of difference in how we navigated this inevitable event.

Geoff Giordano was editor of The Hospitalist from 2007 to 2008. His father, Thomas, a lifelong journalist, wrote several articles for the magazine during that period.

A year ago in March, I looked my father in the eyes for the last time as he mouthed the words "help me" from his ICU bed. But despite being surrounded by teams of medical personnel and the latest healthcare technology, I felt utterly powerless to make a clear decision—and unclear to whom to turn for sound advice.

After 30 days of care in a well-known teaching hospital in the Northeast, my father was about to succumb to Stage 4 lung cancer, a tumor invading his spine. Moments before his plea, the ICU team had conducted a breathing test that apparently went awry—beginning the trial while my mother and I were downstairs receiving the latest round of conflicting information from a pair of doctors debating his outlook for discharge, physical rehabilitation, and hospice care. They casually informed us that a breathing test was about to occur; we rushed back to my father's side to learn the unfortunate outcome.

Prior to the episode that led to his being moved to the ICU, my father had been residing in a room directly across from a small hospitalist oncology office. What ensued was dizzying to behold: an endless parade of consultations; a narrowly averted million-dollar-plus spinal surgery in the wee hours; a too-zealous resident's further injuring of my father's right leg, which had already been compromised by a tumor degrading the femur.

My mother, my wife, and I struggled to maintain Dad's always-indomitable spirit while parsing the barrage of input regarding his potential for quality of life outside the hospital. We sat in numerous meetings, often with a pair of doctors espousing diametrically opposed outlooks. We tried to keep track of whom we were speaking with and who was in charge at any given moment; the lists we kept looked like the roster of a sports team, amply covered in scribbled-out names, phone numbers—and question marks.

It was only after my father tried feebly to speak his last words to me that the doctor who'd appeared to be most in charge pulled me aside at the door of the ICU. My mother and I hemmed and hawed in trying to decide whether to accede to another round of heroic measures. I was surprised by the somewhat terse tone of voice this senior physician used in dissuading us from allowing further life-extending efforts. I would have welcomed such honesty wholeheartedly far earlier in the process.

One of the value propositions hospitalists tout to their employers and patients is their expertise in coordinating care and facilitating communication among caregivers. Of course, there are nearly as many methods for doing so as there are hospitalist teams.

As the medical process grows more complex and specialized, with more "stakeholders" weighing in on the conversation, the hospitalist's role in taking charge of and energetically managing the flow of information for the benefit of beleaguered kin is more vital than ever. I can't speak for all loved ones who must witness the passage of a parent, a child, or a spouse, but for me, a hospitalist's firm hand would have made a world of difference in how we navigated this inevitable event.

Geoff Giordano was editor of The Hospitalist from 2007 to 2008. His father, Thomas, a lifelong journalist, wrote several articles for the magazine during that period.

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