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Consult for an HMG


Consult for an HMG

Question: We are an established hospitalist group going on two years. We started with two full-time physicians and now have five. We obviously have room for improvement and growth. Are there any hospitalist physician consultants who would be able to spend a couple of days with us to evaluate our program and review our systems?

Montell Hutchison,

Business Development Specialist,

Marietta Memorial Hospital,

Marietta, Ohio

Dr. Hospitalist responds: Since the term hospitalist was coined in 1996, the field has grown rapidly. The majority of hospitalist programs are less than five years old. Many hospitalist programs, having grown rapidly over the past few years, are planning to evaluate and improve their performance.

There are a number of options available to help programs benchmark themselves to industry standards. Hiring a consultant is certainly a reasonable choice. SHM has been a particularly valuable resource to help leaders understand how to evaluate their program.

On the Practice Resource section of its Web site (, SHM provides the names and descriptions of several practice management consultants. Also on the site is the downloadable dashboard white paper “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards,” developed by the SHM Benchmarks Committee.

The white paper discusses “issues related to developing, reporting and interpreting performance data.” SHM has also developed the practice management course “Best Practices in Managing a Hospital Medicine Program” and published the book Hospitalists: A Guide to Building and Sustaining a Successful Career to assist those interested in evaluating and improving their hospitalist program.

Lastly, SHM surveys hospitalists every other year to gather productivity and compensation date. The results of the latest “Bi-Annual Survey on the State of the Hospital Medicine Movement” will be released at the SHM Annual Meeting in San Diego April 3-5. Survey information will be available on its Web site shortly thereafter.

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Question: I am a certified diabetes educator with 20 years’ experience in diabetes. I’m about to graduate as an adult nurse practitioner (ANP). My goal is to work with management of inpatient diabetes. Are you aware of any models of ANPs working for or with hospitalists?

Potential Team Member, Ohio

Dr. Hospitalist responds: There are about 20,000 hospitalists in the country. SHM believes that number could grow to 40,000. I am not surprised by the size of that estimate. Just about every hospital I know wants to develop or expand its hospitalist program.

Hospital medicine has filled its ranks over the past decade largely at the expense of primary care. Many physicians have left primary care for hospital medicine. At the same time, many graduates of internal medicine and family medicine training programs have chosen employment in hospital medicine instead of outpatient medicine.

Despite this trend, we are still short of hospitalists. The long-term solution is to expand the numbers of trainees who choose hospital medicine as a career. We are unlikely to see that occur rapidly over the short term. Another potential solution is to increase hospitalist efficiency.

Many in the field are working to redesign systems in the hospital to increase hospitalist efficiency and productivity. Again, these efforts will take time. Adding non-physician providers as care extenders is another viable option many programs are exploring. The results of the latest SHM productivity and compensation survey “Bi-Annual Survey on the State of the Hospital Medicine Movement” being released in April will give a sense of how many midlevel providers (nurse practitioners and physicians’ assistants) are working in hospitalist programs. It will not, however, fully describe their roles and responsibilities. I suspect more hospitalist programs are employing midlevel providers, but the majority of programs do not have midlevel providers among their staff.

For hospitalist programs entertaining the notion of hiring a midlevel provider (and for those midlevel providers interested in joining a hospitalist program), there are barriers to such a relationship. One inherent problem is that most hospitalists do not understand how to work with midlevel providers. Many hospitalists are unaware of the midlevel providers’ education and training.

I am not surprised. Most hospitalists did not work with midlevel providers during their training. There are not only differences in education and training among nurse practitioners (NPs) and physicians’ assistants (PAs), but many state licensing boards also limit their scopes of practice in a different manner. I find that many hospitalists want their midlevel providers to do the scut work hospitalists don’t want to do or feel they don’t have time to do.

I feel this is an expensive way to hire someone to do discharge summaries, put in orders, and make follow-up appointments. One does not need a midlevel education and training to perform those tasks. I suspect most midlevel providers—like hospitalists—find these tasks unsatisfying if it is the majority of their job description. Hospitalist programs would be better served if they involved midlevel providers in the care of patients. But this will require additional training to help hospitalist understand the level of supervision that is necessary for midlevel providers.

For hospitalists who work with midlevel providers, I find too often that many provide too much or too little supervision. Neither is appropriate. Another barrier in some parts of the country relates to the compensation of hospitalists and midlevel providers.

In the Northeast and on the West Coast, for example, we find smaller differences between hospitalist and NP salaries. Since NPs bill at 85% of physician billing, it may not necessarily make financial sense to hire NPs when one can hire a physician at slightly higher cost.

I hope I have not dissuaded you from pursuing a job in hospital medicine. I believe the development of roles for midlevel providers in hospital medicine is critical to the continued expansion of hospital medicine in this country.

I implore hospitalists and midlevel providers to work together to explore and establish models of care that will provide sustainable career opportunities for midlevel providers in hospital medicine. TH

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