Clinical question: Does PR prolongation have any clinical significance in ambulatory adults?

Background: Several studies have suggested that first-degree atrio-ventricular block (AVB) is associated with a benign prognosis. However, these studies were based on young, active men in the military. Another study, which was based on middle-aged men, has suggested that AVB may be associated with coronary artery disease. Little is known about AVB prognosis in ambulatory individuals older than 20 years of age.

Study design: Prospective cohort study.

Setting: Community-hospital-based patients.

Synopsis: A subset population of 7,575 individuals older than 20 from the Framingham Heart Study showed that a prolonged PR interval of more than 200 msec is associated with an increased risk of atrial fibrillation/flutter, pacemaker implantation, and all-cause mortality.

When adjusted for age, sex, cardiovascular disease status, body mass index, hypertension, smoking, diabetes, and ratio of total to high-density lipoprotein cholesterol, individuals with first-degree AVB had a twofold adjusted risk of atrial fibrillation (HR, 2.06; 95% CI, 1.36-3.12; P<0.001), a threefold adjusted risk of pacemaker implantation (HR, 2.89; 95% CI, 1.83-4.57; P<0.001), and 1.4-fold adjusted risk of all-cause mortality (HR, 1.44, 95% CI, 1.09-1.91; P=0.01).

This study was confounded by the usual limitations of the Framingham Study Database. Most notably, this study focused specifically on ambulatory patients with prolonged PR interval demonstrated on routine electrocardiogram and, therefore, does not account for factors commonly related to the inpatient setting, such as electrolyte abnormalities. Hospitalists should neither prognosticate nor plan more frequent follow-up for patients based on a prolonged PR interval based on an EKG obtained during acute illness.

Bottom line: PR prolongation is associated with increased risks of atrial fibrillation/flutter, pacemaker implantation, and all-cause mortality in ambulatory adults.

Citation: Cheng S, Keyes M, Larson M, et al. Long-term outcomes in individuals with prolonged PR interval or first-degree atrioventricular block. JAMA. 2009;301(24):2571-2577.

—Reviewed for The Hospitalist by Robert Chang, MD; Nabil Alkhoury-Fallouh, MD; Anita Hart, MD; Hae-won Kim, MD; Francis McBee-Orzulak, MD; Helena Pasieka, MD; Division of General Medicine, University of Michigan, Ann Arbor

Clinical question: Does PR prolongation have any clinical significance in ambulatory adults?

Background: Several studies have suggested that first-degree atrio-ventricular block (AVB) is associated with a benign prognosis. However, these studies were based on young, active men in the military. Another study, which was based on middle-aged men, has suggested that AVB may be associated with coronary artery disease. Little is known about AVB prognosis in ambulatory individuals older than 20 years of age.

Study design: Prospective cohort study.

Setting: Community-hospital-based patients.

Synopsis: A subset population of 7,575 individuals older than 20 from the Framingham Heart Study showed that a prolonged PR interval of more than 200 msec is associated with an increased risk of atrial fibrillation/flutter, pacemaker implantation, and all-cause mortality.

When adjusted for age, sex, cardiovascular disease status, body mass index, hypertension, smoking, diabetes, and ratio of total to high-density lipoprotein cholesterol, individuals with first-degree AVB had a twofold adjusted risk of atrial fibrillation (HR, 2.06; 95% CI, 1.36-3.12; P<0.001), a threefold adjusted risk of pacemaker implantation (HR, 2.89; 95% CI, 1.83-4.57; P<0.001), and 1.4-fold adjusted risk of all-cause mortality (HR, 1.44, 95% CI, 1.09-1.91; P=0.01).

This study was confounded by the usual limitations of the Framingham Study Database. Most notably, this study focused specifically on ambulatory patients with prolonged PR interval demonstrated on routine electrocardiogram and, therefore, does not account for factors commonly related to the inpatient setting, such as electrolyte abnormalities. Hospitalists should neither prognosticate nor plan more frequent follow-up for patients based on a prolonged PR interval based on an EKG obtained during acute illness.

Bottom line: PR prolongation is associated with increased risks of atrial fibrillation/flutter, pacemaker implantation, and all-cause mortality in ambulatory adults.

Citation: Cheng S, Keyes M, Larson M, et al. Long-term outcomes in individuals with prolonged PR interval or first-degree atrioventricular block. JAMA. 2009;301(24):2571-2577.

—Reviewed for The Hospitalist by Robert Chang, MD; Nabil Alkhoury-Fallouh, MD; Anita Hart, MD; Hae-won Kim, MD; Francis McBee-Orzulak, MD; Helena Pasieka, MD; Division of General Medicine, University of Michigan, Ann Arbor

Clinical question: Does PR prolongation have any clinical significance in ambulatory adults?

Background: Several studies have suggested that first-degree atrio-ventricular block (AVB) is associated with a benign prognosis. However, these studies were based on young, active men in the military. Another study, which was based on middle-aged men, has suggested that AVB may be associated with coronary artery disease. Little is known about AVB prognosis in ambulatory individuals older than 20 years of age.

Study design: Prospective cohort study.

Setting: Community-hospital-based patients.

Synopsis: A subset population of 7,575 individuals older than 20 from the Framingham Heart Study showed that a prolonged PR interval of more than 200 msec is associated with an increased risk of atrial fibrillation/flutter, pacemaker implantation, and all-cause mortality.

When adjusted for age, sex, cardiovascular disease status, body mass index, hypertension, smoking, diabetes, and ratio of total to high-density lipoprotein cholesterol, individuals with first-degree AVB had a twofold adjusted risk of atrial fibrillation (HR, 2.06; 95% CI, 1.36-3.12; P<0.001), a threefold adjusted risk of pacemaker implantation (HR, 2.89; 95% CI, 1.83-4.57; P<0.001), and 1.4-fold adjusted risk of all-cause mortality (HR, 1.44, 95% CI, 1.09-1.91; P=0.01).

This study was confounded by the usual limitations of the Framingham Study Database. Most notably, this study focused specifically on ambulatory patients with prolonged PR interval demonstrated on routine electrocardiogram and, therefore, does not account for factors commonly related to the inpatient setting, such as electrolyte abnormalities. Hospitalists should neither prognosticate nor plan more frequent follow-up for patients based on a prolonged PR interval based on an EKG obtained during acute illness.

Bottom line: PR prolongation is associated with increased risks of atrial fibrillation/flutter, pacemaker implantation, and all-cause mortality in ambulatory adults.

Citation: Cheng S, Keyes M, Larson M, et al. Long-term outcomes in individuals with prolonged PR interval or first-degree atrioventricular block. JAMA. 2009;301(24):2571-2577.

—Reviewed for The Hospitalist by Robert Chang, MD; Nabil Alkhoury-Fallouh, MD; Anita Hart, MD; Hae-won Kim, MD; Francis McBee-Orzulak, MD; Helena Pasieka, MD; Division of General Medicine, University of Michigan, Ann Arbor

New York, NY—A new study suggests that cancer testis antigens (CTAs) should be therapeutically targeted in patients with multiple myeloma (MM).

The study revealed that CTAs are frequently expressed in newly diagnosed MM patients, the presence of certain CTAs can help predict poor survival, and MM patients experience spontaneous antibody responses to CTAs. Adam Cohen, MD, of Fox Chase Cancer Center in Philadelphia, presented this research at Lymphoma & Myeloma 2009, where it was deemed “the best myeloma abstract.”

Dr Cohen and his colleagues enrolled in their study 67 newly diagnosed MM patients. Patients received an induction regimen consisting of thalidomide, doxorubicin, and dexamethasone, and 54 patients went on to receive autologous stem cell transplant.

The researchers assessed CTA expression in cryopreserved pretreatment bone marrow plasma cells. Seventy-seven percent of patients had at least 1 CTA. MAGE-A3 was present in 52% of patients, SSX1 in 40%, CT7 in 29%, CT10 in 25%, NY-ESO1 in 21%, and SSX5 was expressed in 17% of patients. Twenty-nine percent of patients had 3 or more CTAs.

“So the main question was, what was the prognostic significance of these findings?” Dr Cohen said. “We looked at overall survival on the basis of the presence or absence of each of these antigens or based on the absolute number of antigens that were expressed. What we found were 2 antigens that really seemed to stand out, in terms of having prognostic significance.”

Patients who expressed MAGE-A3 or NY-ESO1 had worse overall survival (OS) than patients who expressed other CTAs. OS was a median of 66 months in patients with MAGE-A3 and 65 months in patients with NY-ESO1, while OS was not reached in the other patients.

The poor OS observed in patients with MAGE-A3 and NY-ESO1 was independent of disease stage, cytogenetic abnormalities, and response to induction therapy.

Dr Cohen and his colleagues then assessed pre- and post-treatment sera for antibody responses. Forty-six patients had sera available. Six patients had antibody responses to NY-ESO1. Of these patients, 2 also demonstrated responses to CT7, 1 had response to CT10, and 1 had response to SSX4.

“[A]ll these patients had immunity to NY-ESO1, but in 2 patients, number 30 and 54, there actually was no NY-ESO1 expression in their bone marrow,” Dr Cohen said. “[B]oth of these had extramedullary disease, and so the suggestion was that there may be an additional source of the NY-ESO1 antigen.”  

This theory was supported by the fact that these 2 patients had soft tissue plasmacytomas. And the presence of NY-ESO1 antibody was significantly associated with soft tissue involvement, as 67% of NY-ESO1 antibody-positive patients had soft tissue plasmacytomas.

In addition, antibody response against NY-ESO1 was associated with poor OS. NY-ESO1 antibody-positive patients had an OS of 21 months, while OS was not reached in NY-ESO1 antibody-negative patients.

Dr Cohen presented these data at Lymphoma & Myeloma 2009, which took place October 22-24.

New York, NY—A new study suggests that cancer testis antigens (CTAs) should be therapeutically targeted in patients with multiple myeloma (MM).

The study revealed that CTAs are frequently expressed in newly diagnosed MM patients, the presence of certain CTAs can help predict poor survival, and MM patients experience spontaneous antibody responses to CTAs. Adam Cohen, MD, of Fox Chase Cancer Center in Philadelphia, presented this research at Lymphoma & Myeloma 2009, where it was deemed “the best myeloma abstract.”

Dr Cohen and his colleagues enrolled in their study 67 newly diagnosed MM patients. Patients received an induction regimen consisting of thalidomide, doxorubicin, and dexamethasone, and 54 patients went on to receive autologous stem cell transplant.

The researchers assessed CTA expression in cryopreserved pretreatment bone marrow plasma cells. Seventy-seven percent of patients had at least 1 CTA. MAGE-A3 was present in 52% of patients, SSX1 in 40%, CT7 in 29%, CT10 in 25%, NY-ESO1 in 21%, and SSX5 was expressed in 17% of patients. Twenty-nine percent of patients had 3 or more CTAs.

“So the main question was, what was the prognostic significance of these findings?” Dr Cohen said. “We looked at overall survival on the basis of the presence or absence of each of these antigens or based on the absolute number of antigens that were expressed. What we found were 2 antigens that really seemed to stand out, in terms of having prognostic significance.”

Patients who expressed MAGE-A3 or NY-ESO1 had worse overall survival (OS) than patients who expressed other CTAs. OS was a median of 66 months in patients with MAGE-A3 and 65 months in patients with NY-ESO1, while OS was not reached in the other patients.

The poor OS observed in patients with MAGE-A3 and NY-ESO1 was independent of disease stage, cytogenetic abnormalities, and response to induction therapy.

Dr Cohen and his colleagues then assessed pre- and post-treatment sera for antibody responses. Forty-six patients had sera available. Six patients had antibody responses to NY-ESO1. Of these patients, 2 also demonstrated responses to CT7, 1 had response to CT10, and 1 had response to SSX4.

“[A]ll these patients had immunity to NY-ESO1, but in 2 patients, number 30 and 54, there actually was no NY-ESO1 expression in their bone marrow,” Dr Cohen said. “[B]oth of these had extramedullary disease, and so the suggestion was that there may be an additional source of the NY-ESO1 antigen.”  

This theory was supported by the fact that these 2 patients had soft tissue plasmacytomas. And the presence of NY-ESO1 antibody was significantly associated with soft tissue involvement, as 67% of NY-ESO1 antibody-positive patients had soft tissue plasmacytomas.

In addition, antibody response against NY-ESO1 was associated with poor OS. NY-ESO1 antibody-positive patients had an OS of 21 months, while OS was not reached in NY-ESO1 antibody-negative patients.

Dr Cohen presented these data at Lymphoma & Myeloma 2009, which took place October 22-24.

New York, NY—A new study suggests that cancer testis antigens (CTAs) should be therapeutically targeted in patients with multiple myeloma (MM).

The study revealed that CTAs are frequently expressed in newly diagnosed MM patients, the presence of certain CTAs can help predict poor survival, and MM patients experience spontaneous antibody responses to CTAs. Adam Cohen, MD, of Fox Chase Cancer Center in Philadelphia, presented this research at Lymphoma & Myeloma 2009, where it was deemed “the best myeloma abstract.”

Dr Cohen and his colleagues enrolled in their study 67 newly diagnosed MM patients. Patients received an induction regimen consisting of thalidomide, doxorubicin, and dexamethasone, and 54 patients went on to receive autologous stem cell transplant.

The researchers assessed CTA expression in cryopreserved pretreatment bone marrow plasma cells. Seventy-seven percent of patients had at least 1 CTA. MAGE-A3 was present in 52% of patients, SSX1 in 40%, CT7 in 29%, CT10 in 25%, NY-ESO1 in 21%, and SSX5 was expressed in 17% of patients. Twenty-nine percent of patients had 3 or more CTAs.

“So the main question was, what was the prognostic significance of these findings?” Dr Cohen said. “We looked at overall survival on the basis of the presence or absence of each of these antigens or based on the absolute number of antigens that were expressed. What we found were 2 antigens that really seemed to stand out, in terms of having prognostic significance.”

Patients who expressed MAGE-A3 or NY-ESO1 had worse overall survival (OS) than patients who expressed other CTAs. OS was a median of 66 months in patients with MAGE-A3 and 65 months in patients with NY-ESO1, while OS was not reached in the other patients.

The poor OS observed in patients with MAGE-A3 and NY-ESO1 was independent of disease stage, cytogenetic abnormalities, and response to induction therapy.

Dr Cohen and his colleagues then assessed pre- and post-treatment sera for antibody responses. Forty-six patients had sera available. Six patients had antibody responses to NY-ESO1. Of these patients, 2 also demonstrated responses to CT7, 1 had response to CT10, and 1 had response to SSX4.

“[A]ll these patients had immunity to NY-ESO1, but in 2 patients, number 30 and 54, there actually was no NY-ESO1 expression in their bone marrow,” Dr Cohen said. “[B]oth of these had extramedullary disease, and so the suggestion was that there may be an additional source of the NY-ESO1 antigen.”  

This theory was supported by the fact that these 2 patients had soft tissue plasmacytomas. And the presence of NY-ESO1 antibody was significantly associated with soft tissue involvement, as 67% of NY-ESO1 antibody-positive patients had soft tissue plasmacytomas.

In addition, antibody response against NY-ESO1 was associated with poor OS. NY-ESO1 antibody-positive patients had an OS of 21 months, while OS was not reached in NY-ESO1 antibody-negative patients.

Dr Cohen presented these data at Lymphoma & Myeloma 2009, which took place October 22-24.

John Gilbert, MD, discusses SHM's "Fundamentals of Inpatient Billing and Coding" pre-course at HM09.

Click here to listen to the audio file

John Gilbert, MD, discusses SHM's "Fundamentals of Inpatient Billing and Coding" pre-course at HM09.

Click here to listen to the audio file

John Gilbert, MD, discusses SHM's "Fundamentals of Inpatient Billing and Coding" pre-course at HM09.

Click here to listen to the audio file

AMANE KANEKO

H1N1 Update for Hospital-Based Physicians

Can you relay the latest information regarding swine flu?

K. Thane, MD, Lincoln, Neb.

Dr. Hospitalist responds: Dr. Thane, please do not feel alone. The information regarding 2009 novel H1N1 influenza (swine flu) has been coming out quickly, and the recommendations have been evolving over time. I commend you for your efforts to keep up with the information. All of us have an important role in this pandemic.

I suspect that some of the information I am providing might have changed by the time this article is published. The best advice I can give you is to frequently check the H1N1 flu section of the Centers for Disease Control and Prevention Web site (www.cdc.gov). The CDC’s “FluView” is particularly helpful. It is a weekly “surveillance report” prepared by the CDC’s influenza division. It offers activity estimates reported by “state and territorial epidemiologists.”

Here is a list of what I consider to be the most interesting facts and recommendations regarding the H1N1 pandemic:

5. Fever (93%) and cough (83%) are the most common symptoms of hospitalized patients with the novel H1N1 influenza. Less-frequent symptoms include shortness of breath (54%) and fatigue (40%).

4. Preliminary observation suggests that obesity may be a risk factor for hospitalization and death. A body mass index (BMI) greater than or equal to 40 appears to increase risk of hospitalization and death. Patients with a BMI of 30 to 39 might also be at increased risk.

3. The CDC recommends testing for all patients hospitalized with suspected H1N1 influenza. There are a number of diagnostic tests commercially available to detect the presence of influenza virus in respiratory specimens: cell culture, direct antigen tests, and detection of influenza RNA by reverse transcriptase polymerase chain reaction (rT-PCR). The rT-PCR is the most sensitive and specific test. The test takes about four to six hours and differentiates between influenza types and subtypes.

The rapid influenza detection tests are direct antigen tests that detect influenza viral nucleoproteins. These tests offer the advantage of producing results within 30 minutes, but the sensitivity is lower than viral culture or rT-PCR. Several commercially available rapid antigen tests can differentiate between influenza A and B, but none can differentiate influenza subtypes.

2. All patients at high risk for complications from known or suspected H1N1 influenza should be treated with antiviral medications. Treatment should start as soon as possible, even before laboratory confirmation of infection. High-risk groups include patients 5 years and younger or 65 years and older, pregnant women, those with chronic medical or immunosuppressive conditions, and patients 19 years or younger on chronic aspirin therapy. All patients hospitalized with the novel H1N1 influenza should be treated with antiviral medications regardless of time of symptom onset.

Oseltamivir (Tamiflue) or zanamivir (Relenza) are recommended for treatment. Oseltamivir is administered by mouth, 75 mg twice daily for five days. Zanamivir is orally inhaled, 10 mg every 12 hours for five days. Oseltamivir resistance does not predict Zanamivir resistance.

1. Chemoprophylaxis is recommended for individuals at high risk for complications who were in close contact with an individual with known or suspected H1N1 influenza. It is not necessary in healthy children and adults, and it is not recommended more than 48 hours after exposure. Sitting across a table from a symptomatic patient would not be considered close contact. TH

AMANE KANEKO

H1N1 Update for Hospital-Based Physicians

Can you relay the latest information regarding swine flu?

K. Thane, MD, Lincoln, Neb.

Dr. Hospitalist responds: Dr. Thane, please do not feel alone. The information regarding 2009 novel H1N1 influenza (swine flu) has been coming out quickly, and the recommendations have been evolving over time. I commend you for your efforts to keep up with the information. All of us have an important role in this pandemic.

I suspect that some of the information I am providing might have changed by the time this article is published. The best advice I can give you is to frequently check the H1N1 flu section of the Centers for Disease Control and Prevention Web site (www.cdc.gov). The CDC’s “FluView” is particularly helpful. It is a weekly “surveillance report” prepared by the CDC’s influenza division. It offers activity estimates reported by “state and territorial epidemiologists.”

Here is a list of what I consider to be the most interesting facts and recommendations regarding the H1N1 pandemic:

5. Fever (93%) and cough (83%) are the most common symptoms of hospitalized patients with the novel H1N1 influenza. Less-frequent symptoms include shortness of breath (54%) and fatigue (40%).

4. Preliminary observation suggests that obesity may be a risk factor for hospitalization and death. A body mass index (BMI) greater than or equal to 40 appears to increase risk of hospitalization and death. Patients with a BMI of 30 to 39 might also be at increased risk.

3. The CDC recommends testing for all patients hospitalized with suspected H1N1 influenza. There are a number of diagnostic tests commercially available to detect the presence of influenza virus in respiratory specimens: cell culture, direct antigen tests, and detection of influenza RNA by reverse transcriptase polymerase chain reaction (rT-PCR). The rT-PCR is the most sensitive and specific test. The test takes about four to six hours and differentiates between influenza types and subtypes.

The rapid influenza detection tests are direct antigen tests that detect influenza viral nucleoproteins. These tests offer the advantage of producing results within 30 minutes, but the sensitivity is lower than viral culture or rT-PCR. Several commercially available rapid antigen tests can differentiate between influenza A and B, but none can differentiate influenza subtypes.

2. All patients at high risk for complications from known or suspected H1N1 influenza should be treated with antiviral medications. Treatment should start as soon as possible, even before laboratory confirmation of infection. High-risk groups include patients 5 years and younger or 65 years and older, pregnant women, those with chronic medical or immunosuppressive conditions, and patients 19 years or younger on chronic aspirin therapy. All patients hospitalized with the novel H1N1 influenza should be treated with antiviral medications regardless of time of symptom onset.

Oseltamivir (Tamiflue) or zanamivir (Relenza) are recommended for treatment. Oseltamivir is administered by mouth, 75 mg twice daily for five days. Zanamivir is orally inhaled, 10 mg every 12 hours for five days. Oseltamivir resistance does not predict Zanamivir resistance.

1. Chemoprophylaxis is recommended for individuals at high risk for complications who were in close contact with an individual with known or suspected H1N1 influenza. It is not necessary in healthy children and adults, and it is not recommended more than 48 hours after exposure. Sitting across a table from a symptomatic patient would not be considered close contact. TH

AMANE KANEKO

H1N1 Update for Hospital-Based Physicians

Can you relay the latest information regarding swine flu?

K. Thane, MD, Lincoln, Neb.

Dr. Hospitalist responds: Dr. Thane, please do not feel alone. The information regarding 2009 novel H1N1 influenza (swine flu) has been coming out quickly, and the recommendations have been evolving over time. I commend you for your efforts to keep up with the information. All of us have an important role in this pandemic.

I suspect that some of the information I am providing might have changed by the time this article is published. The best advice I can give you is to frequently check the H1N1 flu section of the Centers for Disease Control and Prevention Web site (www.cdc.gov). The CDC’s “FluView” is particularly helpful. It is a weekly “surveillance report” prepared by the CDC’s influenza division. It offers activity estimates reported by “state and territorial epidemiologists.”

Here is a list of what I consider to be the most interesting facts and recommendations regarding the H1N1 pandemic:

5. Fever (93%) and cough (83%) are the most common symptoms of hospitalized patients with the novel H1N1 influenza. Less-frequent symptoms include shortness of breath (54%) and fatigue (40%).

4. Preliminary observation suggests that obesity may be a risk factor for hospitalization and death. A body mass index (BMI) greater than or equal to 40 appears to increase risk of hospitalization and death. Patients with a BMI of 30 to 39 might also be at increased risk.

3. The CDC recommends testing for all patients hospitalized with suspected H1N1 influenza. There are a number of diagnostic tests commercially available to detect the presence of influenza virus in respiratory specimens: cell culture, direct antigen tests, and detection of influenza RNA by reverse transcriptase polymerase chain reaction (rT-PCR). The rT-PCR is the most sensitive and specific test. The test takes about four to six hours and differentiates between influenza types and subtypes.

The rapid influenza detection tests are direct antigen tests that detect influenza viral nucleoproteins. These tests offer the advantage of producing results within 30 minutes, but the sensitivity is lower than viral culture or rT-PCR. Several commercially available rapid antigen tests can differentiate between influenza A and B, but none can differentiate influenza subtypes.

2. All patients at high risk for complications from known or suspected H1N1 influenza should be treated with antiviral medications. Treatment should start as soon as possible, even before laboratory confirmation of infection. High-risk groups include patients 5 years and younger or 65 years and older, pregnant women, those with chronic medical or immunosuppressive conditions, and patients 19 years or younger on chronic aspirin therapy. All patients hospitalized with the novel H1N1 influenza should be treated with antiviral medications regardless of time of symptom onset.

Oseltamivir (Tamiflue) or zanamivir (Relenza) are recommended for treatment. Oseltamivir is administered by mouth, 75 mg twice daily for five days. Zanamivir is orally inhaled, 10 mg every 12 hours for five days. Oseltamivir resistance does not predict Zanamivir resistance.

1. Chemoprophylaxis is recommended for individuals at high risk for complications who were in close contact with an individual with known or suspected H1N1 influenza. It is not necessary in healthy children and adults, and it is not recommended more than 48 hours after exposure. Sitting across a table from a symptomatic patient would not be considered close contact. TH

Editor’s note: Second of a two-part series.

Many issues that influence hospitalist budgets, specifically the amount of financial support provided by the hospital, are common in most HM practices. Last month I addressed issues related to collecting professional fee revenue (see “Budget Checkup,” October 2009, p. 54). This month I’ll turn to operations that have a significant influence on the practice’s financial picture.

Staffing and Scheduling

My experience is that hospitalists think carefully about the effect of their chosen schedule on a physician’s lifestyle (e.g., make HM a career path and minimize the risk of burnout) and patient-hospitalist continuity. But rarely do I find evidence that the group has acknowledged the effect of their schedules on the budget.

Here’s a common example. As patient volume grows, most groups find that the volume of admissions from late in the afternoon to around 10 or 11 p.m. is too high for one doctor to manage. So the group decides to add an evening shift (often called a “swing shift”). And because all previous shifts in the practice have been 12 hours long, they decide to make the evening shift last 12 hours as well. Many groups adhere to this physician schedule even if patient volume only requires evening-shift coverage from 5 p.m. until around 10 or 11 at night. By choosing a 12-hour evening shift, rather than the five or six hours that are really needed, the practice may be paying for about six hours of unnecessary coverage each day. Six hours more per day is 42 hours per week; I don’t have to tell you that this system can get really expensive very quickly.

Another common example: A group that uses a seven-on/seven-off schedule will add two new full-time equivalent (FTE) employees at the same time to preserve the symmetry required by the schedule, even if patient volume justifies adding only 0.5 to 1.0 FTE.

My point in these examples is not to suggest the right schedule for your group, but to provide a reminder that the schedule has a significant impact on the budget (see “Staffing Strategies,” January 2007, p. 50).

NPP Roles

Physician assistants and nurse practitioners, which I refer to collectively as non-physician providers (NPPs), can make valuable contributions to hospitalist practices. Just as it would do for an MD hospitalist, a practice should assess NPP contribution to important metrics, such as quality of care, throughput, stakeholder satisfaction, and practice economics. I have worked with practices that never give much thought to whether their NPPs occupy the right roles in the practice—positions that allow NPPs to make significant, cost-effective, and career-satisfying contributions.

A simple exercise that can be very helpful is to determine the total cost to employ NPPs (salary and benefits) and think about whether the practice would be better off if those dollars were spent on physicians. If the return on investing in NPPs is less than the return on investing in physicians, the practice should consider adjusting the NPPs’ roles and/or schedules (see “Role Refinement,” September 2009, p. 53).

I’m not suggesting that the only measure of NPP value is in dollars or professional fee revenue billed. Instead, the group’s return on investment should be viewed broadly and include things that don’t appear in financial statements, such as quality, efficiency, patient satisfaction, etc.

Arbitrary Definitions

SHM’s “2007-2008 Bi-Annual Survey on the State of the Hospital Medicine Movement” shows full-time hospitalists work an average of 2,172 hours annually. This might not be a reliable figure. Even so, many practices define full-time work based on annual hours (or shifts), but the doctors regularly adjust actual number of hours worked depending on that day’s workload, and few practices rigorously track actual hours worked. So I think data on hours worked annually (from SHM or other sources) should not be used as reliable or valid target for a practice.

Annual number of shifts worked can be reported by a practice more reliably but usually isn’t included in surveys because shift lengths can vary significantly from one place to the next. Ultimately, the number of hours or shifts that define full-time work for a given practice is arbitrary. And it has an impact on the budget.

Many—maybe most—practices arrive at a definition of full-time work based on annual hours, and any provider who works more than that number is paid for “extra” hours or shifts. If the number of hours or shifts that define full-time work is set low, the practice will end up paying for a lot of extra hours or shifts. Payment beyond the projected salary allowance can cause the practice budget to balloon.

One test to see if this might be an issue in your practice is to total the compensation and productivity (e.g., work relative value units, or wRVUs, or billable encounters) for each doctor in the practice. Analyze how the compensation per wRVU or encounter compares with survey data. If your group is higher than survey data, then the definition of full-time work might be unreasonably low, and vice versa.

Night-Shift Costs

Hospitalist night shifts tend to result in low productivity until the practice has grown enough that there are six to eight daytime hospitalists (rounder/admitter) for every night-shift doctor. Still, most small practices find that it is worthwhile to schedule a separate in-house night shift. The cost of the additional FTEs required to staff a separate night shift can be significant, and is a reason many very small practices require more financial support per FTE hospitalist from the hospital than larger practices.

In most cases, I think it is in the hospital’s best interest to provide support for a separate night shift (see “Finding and Keeping Dedicated Noctornists,” February 2008, p. 61). If the practice budget, or amount of support required of the hospital, is seen as excessive, it is worth estimating how much of the excess is attributable to the expensive night shift.

One simple way to do this is to think about the amount of hospital support that goes to each doctor during each shift. For example, if a hospitalist works 182 shifts a year and is compensated $230,000 (salary and bonus at $200,000, and benefits at $30,000 annually), then the doctor costs the practice $1,264 per shift. You might conduct an analysis and learn that the doctor averages $900 in collected professional fees during a day shift and $500 during a night shift. That means more hospital support goes to cover a night shift ($764) than a day shift ($364). Put another way, in this example, each night shift worked by a doctor requires $400 more hospital support per shift than the day-shift hospitalist ($764 vs. $364). In most cases, the hospital realizes a significant return on spending the extra money on the night shifts.

Hospitalist Productivity

Some hospitals have systems of care that interfere with hospitalist productivity. These could be such things as a poorly organized medical record, an IT system that requires logging into multiple programs to retrieve data on a single patient, or hospitalists being required to do clerical work. Productivity also is influenced by time spent on nonclinical activities, which leads to decreasing professional fee revenue. Every practice should think carefully about the systems and activities that might be getting in the way of efficiency. TH

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

Editor’s note: Second of a two-part series.

Many issues that influence hospitalist budgets, specifically the amount of financial support provided by the hospital, are common in most HM practices. Last month I addressed issues related to collecting professional fee revenue (see “Budget Checkup,” October 2009, p. 54). This month I’ll turn to operations that have a significant influence on the practice’s financial picture.

Staffing and Scheduling

My experience is that hospitalists think carefully about the effect of their chosen schedule on a physician’s lifestyle (e.g., make HM a career path and minimize the risk of burnout) and patient-hospitalist continuity. But rarely do I find evidence that the group has acknowledged the effect of their schedules on the budget.

Here’s a common example. As patient volume grows, most groups find that the volume of admissions from late in the afternoon to around 10 or 11 p.m. is too high for one doctor to manage. So the group decides to add an evening shift (often called a “swing shift”). And because all previous shifts in the practice have been 12 hours long, they decide to make the evening shift last 12 hours as well. Many groups adhere to this physician schedule even if patient volume only requires evening-shift coverage from 5 p.m. until around 10 or 11 at night. By choosing a 12-hour evening shift, rather than the five or six hours that are really needed, the practice may be paying for about six hours of unnecessary coverage each day. Six hours more per day is 42 hours per week; I don’t have to tell you that this system can get really expensive very quickly.

Another common example: A group that uses a seven-on/seven-off schedule will add two new full-time equivalent (FTE) employees at the same time to preserve the symmetry required by the schedule, even if patient volume justifies adding only 0.5 to 1.0 FTE.

My point in these examples is not to suggest the right schedule for your group, but to provide a reminder that the schedule has a significant impact on the budget (see “Staffing Strategies,” January 2007, p. 50).

NPP Roles

Physician assistants and nurse practitioners, which I refer to collectively as non-physician providers (NPPs), can make valuable contributions to hospitalist practices. Just as it would do for an MD hospitalist, a practice should assess NPP contribution to important metrics, such as quality of care, throughput, stakeholder satisfaction, and practice economics. I have worked with practices that never give much thought to whether their NPPs occupy the right roles in the practice—positions that allow NPPs to make significant, cost-effective, and career-satisfying contributions.

A simple exercise that can be very helpful is to determine the total cost to employ NPPs (salary and benefits) and think about whether the practice would be better off if those dollars were spent on physicians. If the return on investing in NPPs is less than the return on investing in physicians, the practice should consider adjusting the NPPs’ roles and/or schedules (see “Role Refinement,” September 2009, p. 53).

I’m not suggesting that the only measure of NPP value is in dollars or professional fee revenue billed. Instead, the group’s return on investment should be viewed broadly and include things that don’t appear in financial statements, such as quality, efficiency, patient satisfaction, etc.

Arbitrary Definitions

SHM’s “2007-2008 Bi-Annual Survey on the State of the Hospital Medicine Movement” shows full-time hospitalists work an average of 2,172 hours annually. This might not be a reliable figure. Even so, many practices define full-time work based on annual hours (or shifts), but the doctors regularly adjust actual number of hours worked depending on that day’s workload, and few practices rigorously track actual hours worked. So I think data on hours worked annually (from SHM or other sources) should not be used as reliable or valid target for a practice.

Annual number of shifts worked can be reported by a practice more reliably but usually isn’t included in surveys because shift lengths can vary significantly from one place to the next. Ultimately, the number of hours or shifts that define full-time work for a given practice is arbitrary. And it has an impact on the budget.

Many—maybe most—practices arrive at a definition of full-time work based on annual hours, and any provider who works more than that number is paid for “extra” hours or shifts. If the number of hours or shifts that define full-time work is set low, the practice will end up paying for a lot of extra hours or shifts. Payment beyond the projected salary allowance can cause the practice budget to balloon.

One test to see if this might be an issue in your practice is to total the compensation and productivity (e.g., work relative value units, or wRVUs, or billable encounters) for each doctor in the practice. Analyze how the compensation per wRVU or encounter compares with survey data. If your group is higher than survey data, then the definition of full-time work might be unreasonably low, and vice versa.

Night-Shift Costs

Hospitalist night shifts tend to result in low productivity until the practice has grown enough that there are six to eight daytime hospitalists (rounder/admitter) for every night-shift doctor. Still, most small practices find that it is worthwhile to schedule a separate in-house night shift. The cost of the additional FTEs required to staff a separate night shift can be significant, and is a reason many very small practices require more financial support per FTE hospitalist from the hospital than larger practices.

In most cases, I think it is in the hospital’s best interest to provide support for a separate night shift (see “Finding and Keeping Dedicated Noctornists,” February 2008, p. 61). If the practice budget, or amount of support required of the hospital, is seen as excessive, it is worth estimating how much of the excess is attributable to the expensive night shift.

One simple way to do this is to think about the amount of hospital support that goes to each doctor during each shift. For example, if a hospitalist works 182 shifts a year and is compensated $230,000 (salary and bonus at $200,000, and benefits at $30,000 annually), then the doctor costs the practice $1,264 per shift. You might conduct an analysis and learn that the doctor averages $900 in collected professional fees during a day shift and $500 during a night shift. That means more hospital support goes to cover a night shift ($764) than a day shift ($364). Put another way, in this example, each night shift worked by a doctor requires $400 more hospital support per shift than the day-shift hospitalist ($764 vs. $364). In most cases, the hospital realizes a significant return on spending the extra money on the night shifts.

Hospitalist Productivity

Some hospitals have systems of care that interfere with hospitalist productivity. These could be such things as a poorly organized medical record, an IT system that requires logging into multiple programs to retrieve data on a single patient, or hospitalists being required to do clerical work. Productivity also is influenced by time spent on nonclinical activities, which leads to decreasing professional fee revenue. Every practice should think carefully about the systems and activities that might be getting in the way of efficiency. TH

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

Editor’s note: Second of a two-part series.

Many issues that influence hospitalist budgets, specifically the amount of financial support provided by the hospital, are common in most HM practices. Last month I addressed issues related to collecting professional fee revenue (see “Budget Checkup,” October 2009, p. 54). This month I’ll turn to operations that have a significant influence on the practice’s financial picture.

Staffing and Scheduling

My experience is that hospitalists think carefully about the effect of their chosen schedule on a physician’s lifestyle (e.g., make HM a career path and minimize the risk of burnout) and patient-hospitalist continuity. But rarely do I find evidence that the group has acknowledged the effect of their schedules on the budget.

Here’s a common example. As patient volume grows, most groups find that the volume of admissions from late in the afternoon to around 10 or 11 p.m. is too high for one doctor to manage. So the group decides to add an evening shift (often called a “swing shift”). And because all previous shifts in the practice have been 12 hours long, they decide to make the evening shift last 12 hours as well. Many groups adhere to this physician schedule even if patient volume only requires evening-shift coverage from 5 p.m. until around 10 or 11 at night. By choosing a 12-hour evening shift, rather than the five or six hours that are really needed, the practice may be paying for about six hours of unnecessary coverage each day. Six hours more per day is 42 hours per week; I don’t have to tell you that this system can get really expensive very quickly.

Another common example: A group that uses a seven-on/seven-off schedule will add two new full-time equivalent (FTE) employees at the same time to preserve the symmetry required by the schedule, even if patient volume justifies adding only 0.5 to 1.0 FTE.

My point in these examples is not to suggest the right schedule for your group, but to provide a reminder that the schedule has a significant impact on the budget (see “Staffing Strategies,” January 2007, p. 50).

NPP Roles

Physician assistants and nurse practitioners, which I refer to collectively as non-physician providers (NPPs), can make valuable contributions to hospitalist practices. Just as it would do for an MD hospitalist, a practice should assess NPP contribution to important metrics, such as quality of care, throughput, stakeholder satisfaction, and practice economics. I have worked with practices that never give much thought to whether their NPPs occupy the right roles in the practice—positions that allow NPPs to make significant, cost-effective, and career-satisfying contributions.

A simple exercise that can be very helpful is to determine the total cost to employ NPPs (salary and benefits) and think about whether the practice would be better off if those dollars were spent on physicians. If the return on investing in NPPs is less than the return on investing in physicians, the practice should consider adjusting the NPPs’ roles and/or schedules (see “Role Refinement,” September 2009, p. 53).

I’m not suggesting that the only measure of NPP value is in dollars or professional fee revenue billed. Instead, the group’s return on investment should be viewed broadly and include things that don’t appear in financial statements, such as quality, efficiency, patient satisfaction, etc.

Arbitrary Definitions

SHM’s “2007-2008 Bi-Annual Survey on the State of the Hospital Medicine Movement” shows full-time hospitalists work an average of 2,172 hours annually. This might not be a reliable figure. Even so, many practices define full-time work based on annual hours (or shifts), but the doctors regularly adjust actual number of hours worked depending on that day’s workload, and few practices rigorously track actual hours worked. So I think data on hours worked annually (from SHM or other sources) should not be used as reliable or valid target for a practice.

Annual number of shifts worked can be reported by a practice more reliably but usually isn’t included in surveys because shift lengths can vary significantly from one place to the next. Ultimately, the number of hours or shifts that define full-time work for a given practice is arbitrary. And it has an impact on the budget.

Many—maybe most—practices arrive at a definition of full-time work based on annual hours, and any provider who works more than that number is paid for “extra” hours or shifts. If the number of hours or shifts that define full-time work is set low, the practice will end up paying for a lot of extra hours or shifts. Payment beyond the projected salary allowance can cause the practice budget to balloon.

One test to see if this might be an issue in your practice is to total the compensation and productivity (e.g., work relative value units, or wRVUs, or billable encounters) for each doctor in the practice. Analyze how the compensation per wRVU or encounter compares with survey data. If your group is higher than survey data, then the definition of full-time work might be unreasonably low, and vice versa.

Night-Shift Costs

Hospitalist night shifts tend to result in low productivity until the practice has grown enough that there are six to eight daytime hospitalists (rounder/admitter) for every night-shift doctor. Still, most small practices find that it is worthwhile to schedule a separate in-house night shift. The cost of the additional FTEs required to staff a separate night shift can be significant, and is a reason many very small practices require more financial support per FTE hospitalist from the hospital than larger practices.

In most cases, I think it is in the hospital’s best interest to provide support for a separate night shift (see “Finding and Keeping Dedicated Noctornists,” February 2008, p. 61). If the practice budget, or amount of support required of the hospital, is seen as excessive, it is worth estimating how much of the excess is attributable to the expensive night shift.

One simple way to do this is to think about the amount of hospital support that goes to each doctor during each shift. For example, if a hospitalist works 182 shifts a year and is compensated $230,000 (salary and bonus at $200,000, and benefits at $30,000 annually), then the doctor costs the practice $1,264 per shift. You might conduct an analysis and learn that the doctor averages $900 in collected professional fees during a day shift and $500 during a night shift. That means more hospital support goes to cover a night shift ($764) than a day shift ($364). Put another way, in this example, each night shift worked by a doctor requires $400 more hospital support per shift than the day-shift hospitalist ($764 vs. $364). In most cases, the hospital realizes a significant return on spending the extra money on the night shifts.

Hospitalist Productivity

Some hospitals have systems of care that interfere with hospitalist productivity. These could be such things as a poorly organized medical record, an IT system that requires logging into multiple programs to retrieve data on a single patient, or hospitalists being required to do clerical work. Productivity also is influenced by time spent on nonclinical activities, which leads to decreasing professional fee revenue. Every practice should think carefully about the systems and activities that might be getting in the way of efficiency. TH

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

“I don’t want to be rude or sarcastic,” he implored rudely and sarcastically, a pretentious smirk materializing, “but for hospital medicine to be considered a specialty, don’t you need to do something ‘special’?”

As I spun my internal Rolodex of responses for a setting-appropriate rebuttal, he exchanged knowing glances with the group of grizzled subspecialist academics surrounding him. The crowd, sensing its young prey was cornered, looked on with pitch-forked stares. The prey, sweaty-palmed and tachycardic, made a valiant yet ultimately futile attempt to stave off the questioner.

This exchange came during the question-and-answer portion of a medical grand rounds presentation that I made as a visiting professor at a major academic medical center many years ago. I was asked to talk about the growing specialty of HM, then a relatively new concept to the starched white coats in the academic ivory tower. To be fair, my interpretation of this interaction might be tainted by transference of an early-career inferiority complex. The inquiry had more than a kernel of legitimacy. Is HM really anything special? That query has lived with me for years in the form of a running internal discussion I’ve had with that questioner’s visage.

A Hospitalist is Born

I distinctly remember the day I became a hospitalist. Unlike for most of you, it wasn’t the day I began practicing as a hospitalist. Rather, it was about two years after I started, when my boss dropped off a brochure to join the National Association of Inpatient Physicians (NAIP). “You should probably join this group, whatever it is,” my nonhospitalist boss said dismissively. I nodded my head approvingly, my face contorting into a deferential and admiring look that indicated appreciation for the boss’s all-knowing greatness (note to my hospitalist group: Read that last sentence again). Moments later, I accessed this group’s Web page and found that the position I’d really been filling, what we called “attending on the medical wards 10 months a year,” was called a “hospitalist.”

OK, I had a name.

But was I special?

Growing Up and Finding Our ‘Disease’

Over the ensuing years, NAIP became SHM, HM textbooks were written, national and local CME meetings sprouted up, and a newsmagazine (this one) and medical journal for hospitalists (Journal of Hospital Medicine) were born.

“That’s terrific,” my imaginary grand rounds visage patronizes, “but a specialty needs more than a few people. It needs a critical mass of providers.”

By the beginning of this decade, the number of hospitalists had surpassed the number of practitioners in such time-honored specialties as geriatrics, critical care, and infectious diseases. By 2005, estimates had hospitalists trumping the number of cardiology and emergency medicine doctors. It is likely that the next decade will see the field mushroom to as many as 50,000, even 70,000, providers.

“But you don’t ‘own’ a disease,” exclaims the organ-centric visage. “You can’t be a specialty without ‘owning’ something.”

About five years ago, SHM decided to embrace VTE as a “hospitalist disease.” For sure, we treat the vast majority of pulmonary embolisms and DVTs, and we are best positioned to prevent the hospital-acquired variants. This, along with the realization that hospitalists care for the vast majority of myocardial infarctions, pneumonia, and stroke cases, provided us several diseases to “own,” or at least share with our subspecialist colleagues. The past decade has seen hospitalists take—and eventually run with—the QI and patient-safety baton. These are not diseases per se, but efforts poised to define the next generation of U.S. healthcare.

Research Agenda

“Let’s be clear,” my visage chides grumpily. “Owning a disease means more than caring for patients with it. You have to build a research agenda and advance the science of that field.”

HM now counts numerous primary research-based training fellowships and hospitalist researchers. The result is a growing cadre of research-funded hospitalists establishing careers in QI, patient safety, and comparative-effectiveness work around inpatient disease states. Additionally, SHM recently decided to begin funding early-career researchers to bolster the ranks of hospitalist researchers.

Training: The Next Frontier

“That’s cute,” the visage condescends, “but come on—you just can’t be a specialty without training programs. How can you be special if anyone coming out of residency training can do what you do?”

This is a question that has preoccupied me for years. Is there really something that hospitalists do that the typical graduating resident isn’t trained to do? The answer is clear to anyone who has reviewed the published literature—or practiced HM.1,2 Necessity dictates that hospitalists become experts in the perioperative management of surgical patients, provide the bulk of care for acute stroke and many neurosurgical patients, be front-line palliative-care providers, and grant a level of medical consultation that is infrequently stressed in residency training.

Moreover, hospitalists require a strong understanding of healthcare finance, transitions of care, and leadership and communication skills that are underemphasized in most training programs. On top of that, we are tasked with improving hospital efficiency, stewarding hospital resources, and tackling the myriad patient safety and QI initiatives being foisted upon American hospitals. Traditional residency training falls short in most of these categories. Educators are taking note, quickly adapting their HM-focused programs.3

“All right, maybe you’re right there, but you can’t be a specialty without certification. Period, end of story,” my friend, now exasperated, states.

Specialty Status

Enter the recently announced American Board of Internal Medicine’s (ABIM) Recognition of Focused Practice (RFP) in Hospital Medicine program. Although the full details have yet to be released, the RFP in HM will utilize the ABIM’s maintenance of certification (MOC) process that all internists are required to partake in at least every 10 years after their initial certification. Certification in HM will most likely include successful completion of four baseline requirements, starting with the ability to document that an applicant has truly focused their practice on inpatient medicine.

Next, diplomates will have to apply their QI skills to HM-based PIMs, or practice improvement modules. Additionally, diplomates will have to complete hospitalist-specific Self-Evaluation Program (SEPs) modules in medical knowledge. And, of course, there will be a secure examination written specifically for hospitalists that is focused on inpatient medicine (see “A-Plus Achievement,” p. 1).

So, as I reminisce fondly with my imaginary visage, it is with the clarity that the next time I give medical grand rounds, I will do so as an unquestioned specialist. TH

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

References

1. Plauth WH III, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247-254.
2. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7): 727-728.
3. Glasheen JJ, Siegal EM, Epstein K, Kutner, J, Prochazka AV. Fulfilling the promise of hospital medicine: Tailoring internal medicine training to address hospitalists’ needs. J Gen Intern Med. 2008;23(7): 1110-1115.

“I don’t want to be rude or sarcastic,” he implored rudely and sarcastically, a pretentious smirk materializing, “but for hospital medicine to be considered a specialty, don’t you need to do something ‘special’?”

As I spun my internal Rolodex of responses for a setting-appropriate rebuttal, he exchanged knowing glances with the group of grizzled subspecialist academics surrounding him. The crowd, sensing its young prey was cornered, looked on with pitch-forked stares. The prey, sweaty-palmed and tachycardic, made a valiant yet ultimately futile attempt to stave off the questioner.

This exchange came during the question-and-answer portion of a medical grand rounds presentation that I made as a visiting professor at a major academic medical center many years ago. I was asked to talk about the growing specialty of HM, then a relatively new concept to the starched white coats in the academic ivory tower. To be fair, my interpretation of this interaction might be tainted by transference of an early-career inferiority complex. The inquiry had more than a kernel of legitimacy. Is HM really anything special? That query has lived with me for years in the form of a running internal discussion I’ve had with that questioner’s visage.

A Hospitalist is Born

I distinctly remember the day I became a hospitalist. Unlike for most of you, it wasn’t the day I began practicing as a hospitalist. Rather, it was about two years after I started, when my boss dropped off a brochure to join the National Association of Inpatient Physicians (NAIP). “You should probably join this group, whatever it is,” my nonhospitalist boss said dismissively. I nodded my head approvingly, my face contorting into a deferential and admiring look that indicated appreciation for the boss’s all-knowing greatness (note to my hospitalist group: Read that last sentence again). Moments later, I accessed this group’s Web page and found that the position I’d really been filling, what we called “attending on the medical wards 10 months a year,” was called a “hospitalist.”

OK, I had a name.

But was I special?

Growing Up and Finding Our ‘Disease’

Over the ensuing years, NAIP became SHM, HM textbooks were written, national and local CME meetings sprouted up, and a newsmagazine (this one) and medical journal for hospitalists (Journal of Hospital Medicine) were born.

“That’s terrific,” my imaginary grand rounds visage patronizes, “but a specialty needs more than a few people. It needs a critical mass of providers.”

By the beginning of this decade, the number of hospitalists had surpassed the number of practitioners in such time-honored specialties as geriatrics, critical care, and infectious diseases. By 2005, estimates had hospitalists trumping the number of cardiology and emergency medicine doctors. It is likely that the next decade will see the field mushroom to as many as 50,000, even 70,000, providers.

“But you don’t ‘own’ a disease,” exclaims the organ-centric visage. “You can’t be a specialty without ‘owning’ something.”

About five years ago, SHM decided to embrace VTE as a “hospitalist disease.” For sure, we treat the vast majority of pulmonary embolisms and DVTs, and we are best positioned to prevent the hospital-acquired variants. This, along with the realization that hospitalists care for the vast majority of myocardial infarctions, pneumonia, and stroke cases, provided us several diseases to “own,” or at least share with our subspecialist colleagues. The past decade has seen hospitalists take—and eventually run with—the QI and patient-safety baton. These are not diseases per se, but efforts poised to define the next generation of U.S. healthcare.

Research Agenda

“Let’s be clear,” my visage chides grumpily. “Owning a disease means more than caring for patients with it. You have to build a research agenda and advance the science of that field.”

HM now counts numerous primary research-based training fellowships and hospitalist researchers. The result is a growing cadre of research-funded hospitalists establishing careers in QI, patient safety, and comparative-effectiveness work around inpatient disease states. Additionally, SHM recently decided to begin funding early-career researchers to bolster the ranks of hospitalist researchers.

Training: The Next Frontier

“That’s cute,” the visage condescends, “but come on—you just can’t be a specialty without training programs. How can you be special if anyone coming out of residency training can do what you do?”

This is a question that has preoccupied me for years. Is there really something that hospitalists do that the typical graduating resident isn’t trained to do? The answer is clear to anyone who has reviewed the published literature—or practiced HM.1,2 Necessity dictates that hospitalists become experts in the perioperative management of surgical patients, provide the bulk of care for acute stroke and many neurosurgical patients, be front-line palliative-care providers, and grant a level of medical consultation that is infrequently stressed in residency training.

Moreover, hospitalists require a strong understanding of healthcare finance, transitions of care, and leadership and communication skills that are underemphasized in most training programs. On top of that, we are tasked with improving hospital efficiency, stewarding hospital resources, and tackling the myriad patient safety and QI initiatives being foisted upon American hospitals. Traditional residency training falls short in most of these categories. Educators are taking note, quickly adapting their HM-focused programs.3

“All right, maybe you’re right there, but you can’t be a specialty without certification. Period, end of story,” my friend, now exasperated, states.

Specialty Status

Enter the recently announced American Board of Internal Medicine’s (ABIM) Recognition of Focused Practice (RFP) in Hospital Medicine program. Although the full details have yet to be released, the RFP in HM will utilize the ABIM’s maintenance of certification (MOC) process that all internists are required to partake in at least every 10 years after their initial certification. Certification in HM will most likely include successful completion of four baseline requirements, starting with the ability to document that an applicant has truly focused their practice on inpatient medicine.

Next, diplomates will have to apply their QI skills to HM-based PIMs, or practice improvement modules. Additionally, diplomates will have to complete hospitalist-specific Self-Evaluation Program (SEPs) modules in medical knowledge. And, of course, there will be a secure examination written specifically for hospitalists that is focused on inpatient medicine (see “A-Plus Achievement,” p. 1).

So, as I reminisce fondly with my imaginary visage, it is with the clarity that the next time I give medical grand rounds, I will do so as an unquestioned specialist. TH

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

References

1. Plauth WH III, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247-254.
2. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7): 727-728.
3. Glasheen JJ, Siegal EM, Epstein K, Kutner, J, Prochazka AV. Fulfilling the promise of hospital medicine: Tailoring internal medicine training to address hospitalists’ needs. J Gen Intern Med. 2008;23(7): 1110-1115.

“I don’t want to be rude or sarcastic,” he implored rudely and sarcastically, a pretentious smirk materializing, “but for hospital medicine to be considered a specialty, don’t you need to do something ‘special’?”

As I spun my internal Rolodex of responses for a setting-appropriate rebuttal, he exchanged knowing glances with the group of grizzled subspecialist academics surrounding him. The crowd, sensing its young prey was cornered, looked on with pitch-forked stares. The prey, sweaty-palmed and tachycardic, made a valiant yet ultimately futile attempt to stave off the questioner.

This exchange came during the question-and-answer portion of a medical grand rounds presentation that I made as a visiting professor at a major academic medical center many years ago. I was asked to talk about the growing specialty of HM, then a relatively new concept to the starched white coats in the academic ivory tower. To be fair, my interpretation of this interaction might be tainted by transference of an early-career inferiority complex. The inquiry had more than a kernel of legitimacy. Is HM really anything special? That query has lived with me for years in the form of a running internal discussion I’ve had with that questioner’s visage.

A Hospitalist is Born

I distinctly remember the day I became a hospitalist. Unlike for most of you, it wasn’t the day I began practicing as a hospitalist. Rather, it was about two years after I started, when my boss dropped off a brochure to join the National Association of Inpatient Physicians (NAIP). “You should probably join this group, whatever it is,” my nonhospitalist boss said dismissively. I nodded my head approvingly, my face contorting into a deferential and admiring look that indicated appreciation for the boss’s all-knowing greatness (note to my hospitalist group: Read that last sentence again). Moments later, I accessed this group’s Web page and found that the position I’d really been filling, what we called “attending on the medical wards 10 months a year,” was called a “hospitalist.”

OK, I had a name.

But was I special?

Growing Up and Finding Our ‘Disease’

Over the ensuing years, NAIP became SHM, HM textbooks were written, national and local CME meetings sprouted up, and a newsmagazine (this one) and medical journal for hospitalists (Journal of Hospital Medicine) were born.

“That’s terrific,” my imaginary grand rounds visage patronizes, “but a specialty needs more than a few people. It needs a critical mass of providers.”

By the beginning of this decade, the number of hospitalists had surpassed the number of practitioners in such time-honored specialties as geriatrics, critical care, and infectious diseases. By 2005, estimates had hospitalists trumping the number of cardiology and emergency medicine doctors. It is likely that the next decade will see the field mushroom to as many as 50,000, even 70,000, providers.

“But you don’t ‘own’ a disease,” exclaims the organ-centric visage. “You can’t be a specialty without ‘owning’ something.”

About five years ago, SHM decided to embrace VTE as a “hospitalist disease.” For sure, we treat the vast majority of pulmonary embolisms and DVTs, and we are best positioned to prevent the hospital-acquired variants. This, along with the realization that hospitalists care for the vast majority of myocardial infarctions, pneumonia, and stroke cases, provided us several diseases to “own,” or at least share with our subspecialist colleagues. The past decade has seen hospitalists take—and eventually run with—the QI and patient-safety baton. These are not diseases per se, but efforts poised to define the next generation of U.S. healthcare.

Research Agenda

“Let’s be clear,” my visage chides grumpily. “Owning a disease means more than caring for patients with it. You have to build a research agenda and advance the science of that field.”

HM now counts numerous primary research-based training fellowships and hospitalist researchers. The result is a growing cadre of research-funded hospitalists establishing careers in QI, patient safety, and comparative-effectiveness work around inpatient disease states. Additionally, SHM recently decided to begin funding early-career researchers to bolster the ranks of hospitalist researchers.

Training: The Next Frontier

“That’s cute,” the visage condescends, “but come on—you just can’t be a specialty without training programs. How can you be special if anyone coming out of residency training can do what you do?”

This is a question that has preoccupied me for years. Is there really something that hospitalists do that the typical graduating resident isn’t trained to do? The answer is clear to anyone who has reviewed the published literature—or practiced HM.1,2 Necessity dictates that hospitalists become experts in the perioperative management of surgical patients, provide the bulk of care for acute stroke and many neurosurgical patients, be front-line palliative-care providers, and grant a level of medical consultation that is infrequently stressed in residency training.

Moreover, hospitalists require a strong understanding of healthcare finance, transitions of care, and leadership and communication skills that are underemphasized in most training programs. On top of that, we are tasked with improving hospital efficiency, stewarding hospital resources, and tackling the myriad patient safety and QI initiatives being foisted upon American hospitals. Traditional residency training falls short in most of these categories. Educators are taking note, quickly adapting their HM-focused programs.3

“All right, maybe you’re right there, but you can’t be a specialty without certification. Period, end of story,” my friend, now exasperated, states.

Specialty Status

Enter the recently announced American Board of Internal Medicine’s (ABIM) Recognition of Focused Practice (RFP) in Hospital Medicine program. Although the full details have yet to be released, the RFP in HM will utilize the ABIM’s maintenance of certification (MOC) process that all internists are required to partake in at least every 10 years after their initial certification. Certification in HM will most likely include successful completion of four baseline requirements, starting with the ability to document that an applicant has truly focused their practice on inpatient medicine.

Next, diplomates will have to apply their QI skills to HM-based PIMs, or practice improvement modules. Additionally, diplomates will have to complete hospitalist-specific Self-Evaluation Program (SEPs) modules in medical knowledge. And, of course, there will be a secure examination written specifically for hospitalists that is focused on inpatient medicine (see “A-Plus Achievement,” p. 1).

So, as I reminisce fondly with my imaginary visage, it is with the clarity that the next time I give medical grand rounds, I will do so as an unquestioned specialist. TH

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

References

1. Plauth WH III, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247-254.
2. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7): 727-728.
3. Glasheen JJ, Siegal EM, Epstein K, Kutner, J, Prochazka AV. Fulfilling the promise of hospital medicine: Tailoring internal medicine training to address hospitalists’ needs. J Gen Intern Med. 2008;23(7): 1110-1115.

When HM was just a twinkle in Bob Wachter’s eye somewhere around 1998, the nascent board of the National Association of Inpatient Physicians (later to become SHM’s board of directors) tried to look forward to the scope and breadth of this new specialty they were hoping to help shape. With just 300 or so hospitalists in the country at that time, it is not surprising that the original board’s vision was that someday hospitalists might replace the inpatient work being done by 30% to 40% of internists and family practitioners. Now, a little more than a decade later, HM has a vista that in some ways can’t be contained inside a hospital’s four walls.

Today, with more than 30,000 hospitalists actively seeing patients in most U.S. hospitals, there has been a reinvention of primary care, with many of the inpatient duties now assumed by hospitalists. Although direct patient care likely will remain the primary role for hospitalists in the foreseeable future, it is not the whole story.

More and more, hospitalists have a leading role in improving the function of the hospital as a cohesive force in the healthcare community. Hospitalists are active in performance-improvement strategies, both in the implementation as well as the measurement and reporting of outcomes. Hospitalists are expected by other hospital health professionals to actively participate in the team approach to healthcare. As hospitals work to reinvent themselves to meet the challenges of the 21st century, whether driven by The Joint Commission, insurers, the business community, or government, the C-suite sees “their” hospitalists as part of the calculus for change.

And as surgical care and subspecialty care evolves, hospitalists are key partners. The fastest-growing aspect of HM today is the growth in the individual hospitalist’s role as the comanager of the surgical or specialty patient. This is much more than a consult. Comanagement involves a division of labor and accountability in which surgeons do what they do best and engage their partner hospitalists to prevent VTE, provide coverage to control perisurgical complications, and share the flow of information to the patients and their families.

So in some sense, the hospitalist provides the multiuse toolbox for all things “hospital,” sort of the Swiss Army knife of healthcare:

• Direct patient care;
• Systems fixer;
• Quality and safety officer;
• Teammate and team leader; and
• Partner to the surgeon and the cardiologist.

It’s quite a lot of value and versatility all wrapped up in one package.

But wait: That is just today. There is more out there on the horizon. (That, by the way, is hospitalist-speak for “some of this is already happening in real time; it’s just not being done by everyone.”)

HM: The Problem-Solver

Hospitalists are being engaged at the ebb and flow of healthcare. Most of us know that even when we do the A-1 job in the hospital that the voltage drops when patients are flung into the white space of the discharge process. Hospitalists know that a patient’s hospitalization doesn’t end at the hospital’s threshold. In many cases, the patient is not cured or returned to full function, but more often than not, the patient is just no longer sick enough to warrant the expense and the intensity of hospitalization.

SHM and our hospitalist leaders have been tackling the discharge process with our Project BOOST (Better Outcomes for Older Adults through Safe Transitions), with funding coming from the Hartford Foundation. Our goals are to give hospitalist-led teams of health professionals the tools and training to reduce unnecessary readmissions and ED visits, and to improve the satisfaction and confidence of our patients and their families. Not an easy task and not one that is over and done, but SHM and our hospitalists have a plan and a path to success.

But wait: There is more.

The patient flow within most hospitals is anything but smooth, error-free, or efficient. The issues develop as the patient travels from the ED to the ICU and out to the floor. The problems arise when multiple physicians manage a patient. There are potential cracks in the system (e.g., shift changes from nurse to nurse, or pharmacist to pharmacist). And, of course, the hospitalist-to-hospitalist handoff still could use some work.

But HM isn’t waiting for someone else to fix this problem. SHM is actively talking to funders about applying some lessons we have learned in our BOOST pilot sites and other performance-improvement efforts. We are beginning to provide the framework to ensure our patients a safe and error-free hospital stay.

It might seem like quite a leap for a specialty that was started to replace direct patient care for a small segment of primary-care physicians. But now, there may be even more for hospitalists to tackle. As policymakers talk of redefining accountabilities, it appears that hospitals will be held financially—and possibly even legally—responsible for patients’ outcomes, not just while they are an inpatient, but for 30 days or more after discharge, too. Tackling this would be daunting if every hospital were surrounded by an entire neighborhood of medical homes, but, of course, that is very much not the case today.

So when the hospital is charged with making sure that their recently discharged patients take the entire course of their prescribed treatment, get the follow-up testing at the right time, follow up on any abnormal results that came up during and after hospitalization, and basically do all the sub-acute care that patients should and often don’t receive, who do you think they will look to?

That’s right: Say hello to the “sub-acutist,” the next member of the hospitalist family tree, which already has nocturnists and SNFists. Most HM groups are busy enough just seeing their inpatients and making the hospital safer, improving quality, and co-managing the surgical and specialty patients. Now it looks as if hospitalist groups will be the fallback to see a patient for the first two or three post-discharge visits, especially when the hospital needs to be accountable for patient outcomes after a patient leaves the hospital. This is definitely not a jump into outpatient medicine, but more of an attempt to “complete” the hospitalization in a new world in which the expectation of the patient and the payor is that the acute illness doesn’t end at the hospital door.

Those of us who think strategically need to analyze what these varied roles for hospitalists mean for the selection of the right people to enter HM, and what education and support the next wave of hospitalists will need to be successful and deliver on the promises being made to our healthcare communities.

SHM and numerous hospitalist companies and organizations are on the leading edge, thinking through these possibilities, and building HM for the future—which, by the way, already is here.

They used to say in a commercial, “This is not your father’s Oldsmobile.” Well, tomorrow’s HM is looking very much like not your older brother’s HM. Love the change; live the change. TH

Dr. Wellikson is CEO of SHM.

When HM was just a twinkle in Bob Wachter’s eye somewhere around 1998, the nascent board of the National Association of Inpatient Physicians (later to become SHM’s board of directors) tried to look forward to the scope and breadth of this new specialty they were hoping to help shape. With just 300 or so hospitalists in the country at that time, it is not surprising that the original board’s vision was that someday hospitalists might replace the inpatient work being done by 30% to 40% of internists and family practitioners. Now, a little more than a decade later, HM has a vista that in some ways can’t be contained inside a hospital’s four walls.

Today, with more than 30,000 hospitalists actively seeing patients in most U.S. hospitals, there has been a reinvention of primary care, with many of the inpatient duties now assumed by hospitalists. Although direct patient care likely will remain the primary role for hospitalists in the foreseeable future, it is not the whole story.

More and more, hospitalists have a leading role in improving the function of the hospital as a cohesive force in the healthcare community. Hospitalists are active in performance-improvement strategies, both in the implementation as well as the measurement and reporting of outcomes. Hospitalists are expected by other hospital health professionals to actively participate in the team approach to healthcare. As hospitals work to reinvent themselves to meet the challenges of the 21st century, whether driven by The Joint Commission, insurers, the business community, or government, the C-suite sees “their” hospitalists as part of the calculus for change.

And as surgical care and subspecialty care evolves, hospitalists are key partners. The fastest-growing aspect of HM today is the growth in the individual hospitalist’s role as the comanager of the surgical or specialty patient. This is much more than a consult. Comanagement involves a division of labor and accountability in which surgeons do what they do best and engage their partner hospitalists to prevent VTE, provide coverage to control perisurgical complications, and share the flow of information to the patients and their families.

So in some sense, the hospitalist provides the multiuse toolbox for all things “hospital,” sort of the Swiss Army knife of healthcare:

• Direct patient care;
• Systems fixer;
• Quality and safety officer;
• Teammate and team leader; and
• Partner to the surgeon and the cardiologist.

It’s quite a lot of value and versatility all wrapped up in one package.

But wait: That is just today. There is more out there on the horizon. (That, by the way, is hospitalist-speak for “some of this is already happening in real time; it’s just not being done by everyone.”)

HM: The Problem-Solver

Hospitalists are being engaged at the ebb and flow of healthcare. Most of us know that even when we do the A-1 job in the hospital that the voltage drops when patients are flung into the white space of the discharge process. Hospitalists know that a patient’s hospitalization doesn’t end at the hospital’s threshold. In many cases, the patient is not cured or returned to full function, but more often than not, the patient is just no longer sick enough to warrant the expense and the intensity of hospitalization.

SHM and our hospitalist leaders have been tackling the discharge process with our Project BOOST (Better Outcomes for Older Adults through Safe Transitions), with funding coming from the Hartford Foundation. Our goals are to give hospitalist-led teams of health professionals the tools and training to reduce unnecessary readmissions and ED visits, and to improve the satisfaction and confidence of our patients and their families. Not an easy task and not one that is over and done, but SHM and our hospitalists have a plan and a path to success.

But wait: There is more.

The patient flow within most hospitals is anything but smooth, error-free, or efficient. The issues develop as the patient travels from the ED to the ICU and out to the floor. The problems arise when multiple physicians manage a patient. There are potential cracks in the system (e.g., shift changes from nurse to nurse, or pharmacist to pharmacist). And, of course, the hospitalist-to-hospitalist handoff still could use some work.

But HM isn’t waiting for someone else to fix this problem. SHM is actively talking to funders about applying some lessons we have learned in our BOOST pilot sites and other performance-improvement efforts. We are beginning to provide the framework to ensure our patients a safe and error-free hospital stay.

It might seem like quite a leap for a specialty that was started to replace direct patient care for a small segment of primary-care physicians. But now, there may be even more for hospitalists to tackle. As policymakers talk of redefining accountabilities, it appears that hospitals will be held financially—and possibly even legally—responsible for patients’ outcomes, not just while they are an inpatient, but for 30 days or more after discharge, too. Tackling this would be daunting if every hospital were surrounded by an entire neighborhood of medical homes, but, of course, that is very much not the case today.

So when the hospital is charged with making sure that their recently discharged patients take the entire course of their prescribed treatment, get the follow-up testing at the right time, follow up on any abnormal results that came up during and after hospitalization, and basically do all the sub-acute care that patients should and often don’t receive, who do you think they will look to?

That’s right: Say hello to the “sub-acutist,” the next member of the hospitalist family tree, which already has nocturnists and SNFists. Most HM groups are busy enough just seeing their inpatients and making the hospital safer, improving quality, and co-managing the surgical and specialty patients. Now it looks as if hospitalist groups will be the fallback to see a patient for the first two or three post-discharge visits, especially when the hospital needs to be accountable for patient outcomes after a patient leaves the hospital. This is definitely not a jump into outpatient medicine, but more of an attempt to “complete” the hospitalization in a new world in which the expectation of the patient and the payor is that the acute illness doesn’t end at the hospital door.

Those of us who think strategically need to analyze what these varied roles for hospitalists mean for the selection of the right people to enter HM, and what education and support the next wave of hospitalists will need to be successful and deliver on the promises being made to our healthcare communities.

SHM and numerous hospitalist companies and organizations are on the leading edge, thinking through these possibilities, and building HM for the future—which, by the way, already is here.

They used to say in a commercial, “This is not your father’s Oldsmobile.” Well, tomorrow’s HM is looking very much like not your older brother’s HM. Love the change; live the change. TH

Dr. Wellikson is CEO of SHM.

When HM was just a twinkle in Bob Wachter’s eye somewhere around 1998, the nascent board of the National Association of Inpatient Physicians (later to become SHM’s board of directors) tried to look forward to the scope and breadth of this new specialty they were hoping to help shape. With just 300 or so hospitalists in the country at that time, it is not surprising that the original board’s vision was that someday hospitalists might replace the inpatient work being done by 30% to 40% of internists and family practitioners. Now, a little more than a decade later, HM has a vista that in some ways can’t be contained inside a hospital’s four walls.

Today, with more than 30,000 hospitalists actively seeing patients in most U.S. hospitals, there has been a reinvention of primary care, with many of the inpatient duties now assumed by hospitalists. Although direct patient care likely will remain the primary role for hospitalists in the foreseeable future, it is not the whole story.

More and more, hospitalists have a leading role in improving the function of the hospital as a cohesive force in the healthcare community. Hospitalists are active in performance-improvement strategies, both in the implementation as well as the measurement and reporting of outcomes. Hospitalists are expected by other hospital health professionals to actively participate in the team approach to healthcare. As hospitals work to reinvent themselves to meet the challenges of the 21st century, whether driven by The Joint Commission, insurers, the business community, or government, the C-suite sees “their” hospitalists as part of the calculus for change.

And as surgical care and subspecialty care evolves, hospitalists are key partners. The fastest-growing aspect of HM today is the growth in the individual hospitalist’s role as the comanager of the surgical or specialty patient. This is much more than a consult. Comanagement involves a division of labor and accountability in which surgeons do what they do best and engage their partner hospitalists to prevent VTE, provide coverage to control perisurgical complications, and share the flow of information to the patients and their families.

So in some sense, the hospitalist provides the multiuse toolbox for all things “hospital,” sort of the Swiss Army knife of healthcare:

• Direct patient care;
• Systems fixer;
• Quality and safety officer;
• Teammate and team leader; and
• Partner to the surgeon and the cardiologist.

It’s quite a lot of value and versatility all wrapped up in one package.

But wait: That is just today. There is more out there on the horizon. (That, by the way, is hospitalist-speak for “some of this is already happening in real time; it’s just not being done by everyone.”)

HM: The Problem-Solver

Hospitalists are being engaged at the ebb and flow of healthcare. Most of us know that even when we do the A-1 job in the hospital that the voltage drops when patients are flung into the white space of the discharge process. Hospitalists know that a patient’s hospitalization doesn’t end at the hospital’s threshold. In many cases, the patient is not cured or returned to full function, but more often than not, the patient is just no longer sick enough to warrant the expense and the intensity of hospitalization.

SHM and our hospitalist leaders have been tackling the discharge process with our Project BOOST (Better Outcomes for Older Adults through Safe Transitions), with funding coming from the Hartford Foundation. Our goals are to give hospitalist-led teams of health professionals the tools and training to reduce unnecessary readmissions and ED visits, and to improve the satisfaction and confidence of our patients and their families. Not an easy task and not one that is over and done, but SHM and our hospitalists have a plan and a path to success.

But wait: There is more.

The patient flow within most hospitals is anything but smooth, error-free, or efficient. The issues develop as the patient travels from the ED to the ICU and out to the floor. The problems arise when multiple physicians manage a patient. There are potential cracks in the system (e.g., shift changes from nurse to nurse, or pharmacist to pharmacist). And, of course, the hospitalist-to-hospitalist handoff still could use some work.

But HM isn’t waiting for someone else to fix this problem. SHM is actively talking to funders about applying some lessons we have learned in our BOOST pilot sites and other performance-improvement efforts. We are beginning to provide the framework to ensure our patients a safe and error-free hospital stay.

It might seem like quite a leap for a specialty that was started to replace direct patient care for a small segment of primary-care physicians. But now, there may be even more for hospitalists to tackle. As policymakers talk of redefining accountabilities, it appears that hospitals will be held financially—and possibly even legally—responsible for patients’ outcomes, not just while they are an inpatient, but for 30 days or more after discharge, too. Tackling this would be daunting if every hospital were surrounded by an entire neighborhood of medical homes, but, of course, that is very much not the case today.

So when the hospital is charged with making sure that their recently discharged patients take the entire course of their prescribed treatment, get the follow-up testing at the right time, follow up on any abnormal results that came up during and after hospitalization, and basically do all the sub-acute care that patients should and often don’t receive, who do you think they will look to?

That’s right: Say hello to the “sub-acutist,” the next member of the hospitalist family tree, which already has nocturnists and SNFists. Most HM groups are busy enough just seeing their inpatients and making the hospital safer, improving quality, and co-managing the surgical and specialty patients. Now it looks as if hospitalist groups will be the fallback to see a patient for the first two or three post-discharge visits, especially when the hospital needs to be accountable for patient outcomes after a patient leaves the hospital. This is definitely not a jump into outpatient medicine, but more of an attempt to “complete” the hospitalization in a new world in which the expectation of the patient and the payor is that the acute illness doesn’t end at the hospital door.

Those of us who think strategically need to analyze what these varied roles for hospitalists mean for the selection of the right people to enter HM, and what education and support the next wave of hospitalists will need to be successful and deliver on the promises being made to our healthcare communities.

SHM and numerous hospitalist companies and organizations are on the leading edge, thinking through these possibilities, and building HM for the future—which, by the way, already is here.

They used to say in a commercial, “This is not your father’s Oldsmobile.” Well, tomorrow’s HM is looking very much like not your older brother’s HM. Love the change; live the change. TH

Dr. Wellikson is CEO of SHM.

It happens every now and then: A physician is providing care to a patient and things aren’t going as smoothly as they should. In fact, the situation is deteriorating. The reasons vary, but the end result is almost always the same, and necessary—the physician-patient relationship must be terminated. When, why, and how the relationship ends can make the difference between an amicable separation and years of litigation. Terminating a relationship with a patient, however, presents special challenges for a hospitalist.

Relationship to Nowhere

Certainly, some days are better than others in all relationships, and physician-patient relationships are no exception.

Hospitalists regularly talk to patients about unpleasant realities. Each patient responds to the information differently. More often than not, these difficult conversations lead to a focused plan for dealing with a patient’s health needs. Sometimes, however, a patient refuses to acknowledge the information provided, responds in an abusive manner to the physician or hospital staff, or is simply noncompliant.

An isolated incident is one thing; an ongoing pattern is another. One key consideration is deterioration of trust—for example, when a physician suspects a patient is malingering or seeking drugs, or the patient lacks confidence in the physician.

Another example is when the hospitalist determines that hospitalization is no longer necessary but the patient or their family does not want the patient discharged. In such cases, a hospitalist cannot continue to order care that is not medically necessary. Nonetheless, if the patient experiences a future adverse outcome, the fact that the patient opposed discharge increases the potential for a lawsuit.

This is particularly true when a patient must be forcibly removed from the hospital. In such cases, it is always best to get another hospitalist and the patient’s primary-care physician involved. Having two or three concurring opinions from outside physicians can help temper the liability risk.

Perhaps most difficult is assessing the impact of external factors on a physician’s ability to provide care. A hospitalist might have a difficult time providing objective care to a patient who is covered by the insurance carrier that is investigating him, the friend of a patient who is suing him, or a close friend or family member. Most state medical boards provide physicians with guidance on “boundary issues,” which boil down to a simple principle: If personal feelings have the appearance of interfering with objective assessment or treatment of the patient, the patient’s care is better left to another hospitalist.

Transitioning Care and Abandonment

Deciding that a physician-patient relationship is no longer productive is only the beginning of a termination. Prohibitions on patient “abandonment” restrict a physician’s ability to immediately terminate a relationship. Particularly when a patient objects to discharge, it is extremely important to have a comprehensive post-discharge plan. Such a plan must include ensuring that outpatient care providers are available and willing to see the patient.

Even transitioning care to another provider must be handled carefully. As a hospitalist, you first must ensure that another provider is able to promptly take responsibility. It is not enough to just call the service to assign a new hospitalist. Rather, your responsibilities end only when the new provider sees the patient. Moreover, there should be a “handoff” so you can pinpoint when your obligations to the patient officially end.

Discrimination

Physicians may not refuse to treat a patient for a discriminatory reason. For example, federal and state laws prohibit discrimination based on race, religion, sex, national origin, disability, or age. Additionally, some states prohibit discrimination based on sexual orientation. So while a physician can decide not to treat lawyers (not a protected class), they are not allowed to refuse to treat someone because they are Hispanic, Muslim, or homosexual.

Conclusion

The simple answer to the question of when to terminate a physician-patient relationship is: whenever a conflict arises that is likely to impact the provision of care. Terminating the relationship in a manner that protects both the patient and the physician is the key to reducing potential liability. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.

Image Source: CIMMERIAN/ISTOCKPHOTO.COM

It happens every now and then: A physician is providing care to a patient and things aren’t going as smoothly as they should. In fact, the situation is deteriorating. The reasons vary, but the end result is almost always the same, and necessary—the physician-patient relationship must be terminated. When, why, and how the relationship ends can make the difference between an amicable separation and years of litigation. Terminating a relationship with a patient, however, presents special challenges for a hospitalist.

Relationship to Nowhere

Certainly, some days are better than others in all relationships, and physician-patient relationships are no exception.

Hospitalists regularly talk to patients about unpleasant realities. Each patient responds to the information differently. More often than not, these difficult conversations lead to a focused plan for dealing with a patient’s health needs. Sometimes, however, a patient refuses to acknowledge the information provided, responds in an abusive manner to the physician or hospital staff, or is simply noncompliant.

An isolated incident is one thing; an ongoing pattern is another. One key consideration is deterioration of trust—for example, when a physician suspects a patient is malingering or seeking drugs, or the patient lacks confidence in the physician.

Another example is when the hospitalist determines that hospitalization is no longer necessary but the patient or their family does not want the patient discharged. In such cases, a hospitalist cannot continue to order care that is not medically necessary. Nonetheless, if the patient experiences a future adverse outcome, the fact that the patient opposed discharge increases the potential for a lawsuit.

This is particularly true when a patient must be forcibly removed from the hospital. In such cases, it is always best to get another hospitalist and the patient’s primary-care physician involved. Having two or three concurring opinions from outside physicians can help temper the liability risk.

Perhaps most difficult is assessing the impact of external factors on a physician’s ability to provide care. A hospitalist might have a difficult time providing objective care to a patient who is covered by the insurance carrier that is investigating him, the friend of a patient who is suing him, or a close friend or family member. Most state medical boards provide physicians with guidance on “boundary issues,” which boil down to a simple principle: If personal feelings have the appearance of interfering with objective assessment or treatment of the patient, the patient’s care is better left to another hospitalist.

Transitioning Care and Abandonment

Deciding that a physician-patient relationship is no longer productive is only the beginning of a termination. Prohibitions on patient “abandonment” restrict a physician’s ability to immediately terminate a relationship. Particularly when a patient objects to discharge, it is extremely important to have a comprehensive post-discharge plan. Such a plan must include ensuring that outpatient care providers are available and willing to see the patient.

Even transitioning care to another provider must be handled carefully. As a hospitalist, you first must ensure that another provider is able to promptly take responsibility. It is not enough to just call the service to assign a new hospitalist. Rather, your responsibilities end only when the new provider sees the patient. Moreover, there should be a “handoff” so you can pinpoint when your obligations to the patient officially end.

Discrimination

Physicians may not refuse to treat a patient for a discriminatory reason. For example, federal and state laws prohibit discrimination based on race, religion, sex, national origin, disability, or age. Additionally, some states prohibit discrimination based on sexual orientation. So while a physician can decide not to treat lawyers (not a protected class), they are not allowed to refuse to treat someone because they are Hispanic, Muslim, or homosexual.

Conclusion

The simple answer to the question of when to terminate a physician-patient relationship is: whenever a conflict arises that is likely to impact the provision of care. Terminating the relationship in a manner that protects both the patient and the physician is the key to reducing potential liability. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.

Image Source: CIMMERIAN/ISTOCKPHOTO.COM

It happens every now and then: A physician is providing care to a patient and things aren’t going as smoothly as they should. In fact, the situation is deteriorating. The reasons vary, but the end result is almost always the same, and necessary—the physician-patient relationship must be terminated. When, why, and how the relationship ends can make the difference between an amicable separation and years of litigation. Terminating a relationship with a patient, however, presents special challenges for a hospitalist.

Relationship to Nowhere

Certainly, some days are better than others in all relationships, and physician-patient relationships are no exception.

Hospitalists regularly talk to patients about unpleasant realities. Each patient responds to the information differently. More often than not, these difficult conversations lead to a focused plan for dealing with a patient’s health needs. Sometimes, however, a patient refuses to acknowledge the information provided, responds in an abusive manner to the physician or hospital staff, or is simply noncompliant.

An isolated incident is one thing; an ongoing pattern is another. One key consideration is deterioration of trust—for example, when a physician suspects a patient is malingering or seeking drugs, or the patient lacks confidence in the physician.

Another example is when the hospitalist determines that hospitalization is no longer necessary but the patient or their family does not want the patient discharged. In such cases, a hospitalist cannot continue to order care that is not medically necessary. Nonetheless, if the patient experiences a future adverse outcome, the fact that the patient opposed discharge increases the potential for a lawsuit.

This is particularly true when a patient must be forcibly removed from the hospital. In such cases, it is always best to get another hospitalist and the patient’s primary-care physician involved. Having two or three concurring opinions from outside physicians can help temper the liability risk.

Perhaps most difficult is assessing the impact of external factors on a physician’s ability to provide care. A hospitalist might have a difficult time providing objective care to a patient who is covered by the insurance carrier that is investigating him, the friend of a patient who is suing him, or a close friend or family member. Most state medical boards provide physicians with guidance on “boundary issues,” which boil down to a simple principle: If personal feelings have the appearance of interfering with objective assessment or treatment of the patient, the patient’s care is better left to another hospitalist.

Transitioning Care and Abandonment

Deciding that a physician-patient relationship is no longer productive is only the beginning of a termination. Prohibitions on patient “abandonment” restrict a physician’s ability to immediately terminate a relationship. Particularly when a patient objects to discharge, it is extremely important to have a comprehensive post-discharge plan. Such a plan must include ensuring that outpatient care providers are available and willing to see the patient.

Even transitioning care to another provider must be handled carefully. As a hospitalist, you first must ensure that another provider is able to promptly take responsibility. It is not enough to just call the service to assign a new hospitalist. Rather, your responsibilities end only when the new provider sees the patient. Moreover, there should be a “handoff” so you can pinpoint when your obligations to the patient officially end.

Discrimination

Physicians may not refuse to treat a patient for a discriminatory reason. For example, federal and state laws prohibit discrimination based on race, religion, sex, national origin, disability, or age. Additionally, some states prohibit discrimination based on sexual orientation. So while a physician can decide not to treat lawyers (not a protected class), they are not allowed to refuse to treat someone because they are Hispanic, Muslim, or homosexual.

Conclusion

The simple answer to the question of when to terminate a physician-patient relationship is: whenever a conflict arises that is likely to impact the provision of care. Terminating the relationship in a manner that protects both the patient and the physician is the key to reducing potential liability. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.

Image Source: CIMMERIAN/ISTOCKPHOTO.COM

While spending a summer taking care of her mother-in-law, who was ill with colon cancer, Lynne Allen, MN, ARNP, heard her calling loud and clear. “I thought, ‘Wow, I can do this,’ ” she says. “A lot of people can’t do this.”

Allen had completed a year of nursing school right after high school but never finished. So she decided to go back to school and earn a nursing degree. She graduated from the University of Washington’s Adult Acute Care Nurse Practitioner Program in 2001 and later landed a job at Columbia Basin Hematology and Oncology, a private practice in Kennewick, Wash.

At the time, a then-burgeoning hospitalist group based in Brentwood, Tenn., was looking to recruit nurses. Cogent Healthcare made Allen an offer. The idea of working in a hospital where doctors would be available 24 hours a day, seven days a week, intrigued Allen. “I was a house supervisor in grad school and always remember thinking, ‘If only I had a physician in here, I could take care of this problem in two minutes,’ ” she says.

Allen accepted the offer and went to work in Cogent’s nonphysician clinical development program. Last year, she returned to Columbia Basin, where she makes hospitalist rounds four times a week at Kadlec Regional Medical Center in Richland, Wash. Allen, the newest member of Team Hospitalist, recently spoke with The Hospitalist about the unique perspective nurse practitioners (NPs) offer HM.

Question: What do you like about working with hospitalists?

Answer: I like the teamwork involved. I really like going in the morning and seeing that the nurses cared for the patients all night and know what is going on. I like knowing that they can feel comfortable calling me about what they need and making a difference. In terms of hospital medicine, just because [a patient] stays a long time doesn’t mean they are getting the quality of care they need. There are other issues involved with that, especially in cancer patients. They are afraid to go home, afraid of dying. If you have a patient with cancer or COPD [chronic obstructive pulmonary disease] and they are probably not going to live as long as they would normally, you begin to talk to them about their goals for themselves, in terms of quality of life.

Q: How do you initiate that conversation?

A: Medicare has made it very easy, because every patient that comes in should be asked if they have a living will, so you bring that subject up. Most people, when they are dying, they know it. The rest of the family is surprised, but the patient knows it. Sometimes you just bring it up point-blank.

PHOTOS COURTESY OF LYNNE ALLEN

Q: Why does HM present an opportunity for NPs?

A: I think workforce is one of the issues. I think there are a lot of nurses out there who have worked in a hospital and love that acute-care environment. It is very different than working in a clinic. I do both right now, and there is such a difference in what you need to know about your patients and how you treat them.

Q: How is it different?

A: When you are in an outpatient center, [patients] are there and you are probably giving them meds if they are getting chemotherapy and need some support. In an inpatient setting, they are there all the time. It’s a 24/7 need for support. I see this as another special area NPs can take. It’s in the stage of infancy, and it will grow.

Q: Do you think your background in nursing has helped you interact better with patients?

A: Yes. It is part of “who” nurses are. I really enjoy being able to take care of the patients that need the open communication, because it does help them.

Q: What unique perspective do NPs bring to HM?

A: I think nurses are taught to look at the whole patient. We are not taught to specifically say, “This patient has these symptoms, this disease process, this treatment.” … They have family. They have social issues. They have spiritual issues. [It all plays] into their disease process and their treatment process.

Q: What’s the one thing about NPs that most hospitalists don’t get?

A: We are trained to practice independently. In my state, Washington, I can be a completely independent practitioner. We are also taught to know when to consult or collaborate with a physician. I think sometimes physicians don’t recognize that or understand that. They think that we just want to be more independent. HM is a team effort, and we are willing to be part of the team with an equal partnership.

Q: What are some of the issues that come up between NPs and hospitalists?

A: Physicians are not trained to delegate. They are trained that you are in control, you are the one in charge of this patient’s care, you will dictate what goes on with this patient. Medicare and Medicaid require an attending physician, so for a physician to put [his or her] name on there and trust someone else to assess and develop a care plan is hard for them. And I can’t blame them.

Give it a chance, work together, and develop that relationship. Don’t expect it to be there right at day one. And it might not even be six months, but you need to be open-minded and willing to work with someone who is willing to work with you, and not just think it is about giving orders.

Q: What qualities should hospitalists look for in hiring NPs?

A: They should look for someone who has actually worked in a hospital, who is interested in working on a team, who is interested in developing their own capacity or intellectual ability to take care of patients—and recognize that there is going to be a learning curve there. They should also look for someone who is pleasant and who seems to fit in with the team. TH

Stephanie Cajigal is associate editor of The Hospitalist.

While spending a summer taking care of her mother-in-law, who was ill with colon cancer, Lynne Allen, MN, ARNP, heard her calling loud and clear. “I thought, ‘Wow, I can do this,’ ” she says. “A lot of people can’t do this.”

Allen had completed a year of nursing school right after high school but never finished. So she decided to go back to school and earn a nursing degree. She graduated from the University of Washington’s Adult Acute Care Nurse Practitioner Program in 2001 and later landed a job at Columbia Basin Hematology and Oncology, a private practice in Kennewick, Wash.

At the time, a then-burgeoning hospitalist group based in Brentwood, Tenn., was looking to recruit nurses. Cogent Healthcare made Allen an offer. The idea of working in a hospital where doctors would be available 24 hours a day, seven days a week, intrigued Allen. “I was a house supervisor in grad school and always remember thinking, ‘If only I had a physician in here, I could take care of this problem in two minutes,’ ” she says.

Allen accepted the offer and went to work in Cogent’s nonphysician clinical development program. Last year, she returned to Columbia Basin, where she makes hospitalist rounds four times a week at Kadlec Regional Medical Center in Richland, Wash. Allen, the newest member of Team Hospitalist, recently spoke with The Hospitalist about the unique perspective nurse practitioners (NPs) offer HM.

Question: What do you like about working with hospitalists?

Answer: I like the teamwork involved. I really like going in the morning and seeing that the nurses cared for the patients all night and know what is going on. I like knowing that they can feel comfortable calling me about what they need and making a difference. In terms of hospital medicine, just because [a patient] stays a long time doesn’t mean they are getting the quality of care they need. There are other issues involved with that, especially in cancer patients. They are afraid to go home, afraid of dying. If you have a patient with cancer or COPD [chronic obstructive pulmonary disease] and they are probably not going to live as long as they would normally, you begin to talk to them about their goals for themselves, in terms of quality of life.

Q: How do you initiate that conversation?

A: Medicare has made it very easy, because every patient that comes in should be asked if they have a living will, so you bring that subject up. Most people, when they are dying, they know it. The rest of the family is surprised, but the patient knows it. Sometimes you just bring it up point-blank.

PHOTOS COURTESY OF LYNNE ALLEN

Q: Why does HM present an opportunity for NPs?

A: I think workforce is one of the issues. I think there are a lot of nurses out there who have worked in a hospital and love that acute-care environment. It is very different than working in a clinic. I do both right now, and there is such a difference in what you need to know about your patients and how you treat them.

Q: How is it different?

A: When you are in an outpatient center, [patients] are there and you are probably giving them meds if they are getting chemotherapy and need some support. In an inpatient setting, they are there all the time. It’s a 24/7 need for support. I see this as another special area NPs can take. It’s in the stage of infancy, and it will grow.

Q: Do you think your background in nursing has helped you interact better with patients?

A: Yes. It is part of “who” nurses are. I really enjoy being able to take care of the patients that need the open communication, because it does help them.

Q: What unique perspective do NPs bring to HM?

A: I think nurses are taught to look at the whole patient. We are not taught to specifically say, “This patient has these symptoms, this disease process, this treatment.” … They have family. They have social issues. They have spiritual issues. [It all plays] into their disease process and their treatment process.

Q: What’s the one thing about NPs that most hospitalists don’t get?

A: We are trained to practice independently. In my state, Washington, I can be a completely independent practitioner. We are also taught to know when to consult or collaborate with a physician. I think sometimes physicians don’t recognize that or understand that. They think that we just want to be more independent. HM is a team effort, and we are willing to be part of the team with an equal partnership.

Q: What are some of the issues that come up between NPs and hospitalists?

A: Physicians are not trained to delegate. They are trained that you are in control, you are the one in charge of this patient’s care, you will dictate what goes on with this patient. Medicare and Medicaid require an attending physician, so for a physician to put [his or her] name on there and trust someone else to assess and develop a care plan is hard for them. And I can’t blame them.

Give it a chance, work together, and develop that relationship. Don’t expect it to be there right at day one. And it might not even be six months, but you need to be open-minded and willing to work with someone who is willing to work with you, and not just think it is about giving orders.

Q: What qualities should hospitalists look for in hiring NPs?

A: They should look for someone who has actually worked in a hospital, who is interested in working on a team, who is interested in developing their own capacity or intellectual ability to take care of patients—and recognize that there is going to be a learning curve there. They should also look for someone who is pleasant and who seems to fit in with the team. TH

Stephanie Cajigal is associate editor of The Hospitalist.

While spending a summer taking care of her mother-in-law, who was ill with colon cancer, Lynne Allen, MN, ARNP, heard her calling loud and clear. “I thought, ‘Wow, I can do this,’ ” she says. “A lot of people can’t do this.”

Allen had completed a year of nursing school right after high school but never finished. So she decided to go back to school and earn a nursing degree. She graduated from the University of Washington’s Adult Acute Care Nurse Practitioner Program in 2001 and later landed a job at Columbia Basin Hematology and Oncology, a private practice in Kennewick, Wash.

At the time, a then-burgeoning hospitalist group based in Brentwood, Tenn., was looking to recruit nurses. Cogent Healthcare made Allen an offer. The idea of working in a hospital where doctors would be available 24 hours a day, seven days a week, intrigued Allen. “I was a house supervisor in grad school and always remember thinking, ‘If only I had a physician in here, I could take care of this problem in two minutes,’ ” she says.

Allen accepted the offer and went to work in Cogent’s nonphysician clinical development program. Last year, she returned to Columbia Basin, where she makes hospitalist rounds four times a week at Kadlec Regional Medical Center in Richland, Wash. Allen, the newest member of Team Hospitalist, recently spoke with The Hospitalist about the unique perspective nurse practitioners (NPs) offer HM.

Question: What do you like about working with hospitalists?

Answer: I like the teamwork involved. I really like going in the morning and seeing that the nurses cared for the patients all night and know what is going on. I like knowing that they can feel comfortable calling me about what they need and making a difference. In terms of hospital medicine, just because [a patient] stays a long time doesn’t mean they are getting the quality of care they need. There are other issues involved with that, especially in cancer patients. They are afraid to go home, afraid of dying. If you have a patient with cancer or COPD [chronic obstructive pulmonary disease] and they are probably not going to live as long as they would normally, you begin to talk to them about their goals for themselves, in terms of quality of life.

Q: How do you initiate that conversation?

A: Medicare has made it very easy, because every patient that comes in should be asked if they have a living will, so you bring that subject up. Most people, when they are dying, they know it. The rest of the family is surprised, but the patient knows it. Sometimes you just bring it up point-blank.

PHOTOS COURTESY OF LYNNE ALLEN

Q: Why does HM present an opportunity for NPs?

A: I think workforce is one of the issues. I think there are a lot of nurses out there who have worked in a hospital and love that acute-care environment. It is very different than working in a clinic. I do both right now, and there is such a difference in what you need to know about your patients and how you treat them.

Q: How is it different?

A: When you are in an outpatient center, [patients] are there and you are probably giving them meds if they are getting chemotherapy and need some support. In an inpatient setting, they are there all the time. It’s a 24/7 need for support. I see this as another special area NPs can take. It’s in the stage of infancy, and it will grow.

Q: Do you think your background in nursing has helped you interact better with patients?

A: Yes. It is part of “who” nurses are. I really enjoy being able to take care of the patients that need the open communication, because it does help them.

Q: What unique perspective do NPs bring to HM?

A: I think nurses are taught to look at the whole patient. We are not taught to specifically say, “This patient has these symptoms, this disease process, this treatment.” … They have family. They have social issues. They have spiritual issues. [It all plays] into their disease process and their treatment process.

Q: What’s the one thing about NPs that most hospitalists don’t get?

A: We are trained to practice independently. In my state, Washington, I can be a completely independent practitioner. We are also taught to know when to consult or collaborate with a physician. I think sometimes physicians don’t recognize that or understand that. They think that we just want to be more independent. HM is a team effort, and we are willing to be part of the team with an equal partnership.

Q: What are some of the issues that come up between NPs and hospitalists?

A: Physicians are not trained to delegate. They are trained that you are in control, you are the one in charge of this patient’s care, you will dictate what goes on with this patient. Medicare and Medicaid require an attending physician, so for a physician to put [his or her] name on there and trust someone else to assess and develop a care plan is hard for them. And I can’t blame them.

Give it a chance, work together, and develop that relationship. Don’t expect it to be there right at day one. And it might not even be six months, but you need to be open-minded and willing to work with someone who is willing to work with you, and not just think it is about giving orders.

Q: What qualities should hospitalists look for in hiring NPs?

A: They should look for someone who has actually worked in a hospital, who is interested in working on a team, who is interested in developing their own capacity or intellectual ability to take care of patients—and recognize that there is going to be a learning curve there. They should also look for someone who is pleasant and who seems to fit in with the team. TH

Stephanie Cajigal is associate editor of The Hospitalist.

One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.

Discharge Day Management

Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.

A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.

It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2

Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.

Shared/Split Services

Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).

The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.

In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3

Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4

Teaching Physician Services

A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.

The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.

Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
4. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
5. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
6. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
8. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.

One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.

Discharge Day Management

Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.

A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.

It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2

Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.

Shared/Split Services

Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).

The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.

In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3

Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4

Teaching Physician Services

A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.

The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.

Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
4. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
5. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
6. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
8. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.

One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.

Discharge Day Management

Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.

A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.

It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2

Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.

Shared/Split Services

Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).

The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.

In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3

Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4

Teaching Physician Services

A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.

The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.

Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
4. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
5. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
6. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
8. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.