Medicolegal Issues

Industry Innovator Eyes HM Challenges Ahead


 

Brian Bossard, MD, was practicing as a hospitalist before he even knew what a hospitalist was. In 1993, Dr. Bossard, then a private practice internist, initiated a contract with Lincoln General Hospital in Lincoln, Neb. He agreed to care for hospital patients who didn’t have physicians. The hospital signed the contract—three years before HM pioneer Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California San Francisco, former SHM president and author of the blog “Wachter’s World” (www.wachtersworld.com), coined the term “hospitalist.”

Dr. Bossard, director and CEO of Inpatient Physician Associates in Lincoln, recently spoke with The Hospitalist about being at the forefront of the hospital medicine movement.

Q: How did you come to form your own hospitalist group?

When I started my group, I was able to recruit a strong, core group of five physicians in six months. I don’t think there is any way you could do that now.


—Brian Bossard, MD

A: [Starting in 1993], I was providing hospital medicine service while at the same time working in a private practice model. I took care of my own patients and also took care of all the assigned patients through the hospital. During that period, I started getting referrals from other physicians who wanted to turn their patients’ care over to me. It became clear after just a few years of doing that I was getting very busy and that there was a need for a more formal hospital medicine program. So, beginning in 1998, I started going to national hospital medicine meetings. I took my hospital administrator with me to the first meeting, and during the next four years developed an infrastructure for a mature hospital medicine program.

Q: What trends have you identified in HM since that time?

A: In the case of academic medicine models, hospital medicine developed because they needed to have a system to provide a cap for the residents—both in terms of number of hours they worked and the number of patients they saw. That was a new development and one that wasn’t in place when I went through training.

Private practice or community-based hospitals had physicians who were no longer interested in providing community call for taking care of patients that didn’t have physicians, or maybe didn’t have insurance. Community hospitals were finding that many physicians were opting out of that community call so they needed hospital medicine support to take care of those patients.

Q: What is the most significant change you’ve witnessed?

A: It’s become clear hospital medicine programs not only provide staffing to take care of those patients who otherwise wouldn’t be taken care of, but also provide a structure to take care of patients better. Probably the most positive and meaningful change since the mid-’90s is that hospital medicine programs are seen as quality drivers, efficiency drivers, and as a source of leadership within hospital policy making and decision making.

Q: What are your responsibilities as CEO of your group?

A: I run the business from top to bottom. Since I started the group in 2002, we’ve grown from just six physicians to 18 physicians and three nurse coordinators. So, I’ve had an opportunity during the last seven years to develop leadership roles within our group and delegate some activities to other leaders in the group. Where I once oversaw every little detail, I am now able to turn over some things to other, very talented group members. What I really focus on now is recruitment, the clinical aspects, public relations, and those sorts of things. But I never lose sight of the importance of developing data to drive our decisions, so I’m very involved in that, as well. As we add more and more physicians, I have to dedicate more time to management of the group. My clinical time goes down as the group grows.

Q: You mentioned that you collect data?

A: I work with the folks in the IT and Division Analysis departments in the hospital to identify what data we can get, what is important for me to know … so we can make decisions for the better of the group and the hospital. Some of that involves knowing what time of the day we have the highest admissions consults and what days of the week we’re busiest, and then organizing our schedule accordingly. It’s important to look at numbers and data, as opposed to going by when you feel you’re busy and when you’re not, because sometimes the feel is different from what is actually happening.

Q: What are the challenges facing your HMG?

A: Recruitment is a huge challenge. The growth of hospital medicine is much greater than anticipated even five years ago. Many programs are understaffed right now. That’s not because they don’t have financing, but because they don’t have physicians available to staff the slots. When I started my group, I was able to recruit a strong, core group of five physicians in six months. I don’t think there is any way you could do that now. That’s a trend that’s changed for the worst. I don’t think internal medicine is going to be able to support the need for care providers within hospital medicine programs.

Q: How should hospital medicine groups look to fill their vacancies?

A: I think opportunities will exist for well-trained and motivated family medicine physicians. Many more rural or community-based hospitals are turning to family physicians to staff programs. Typically, family physicians represent only 3% of hospital medicine program slots. I see that percentage increasing fairly significantly in the next five years. TH

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