HOSPITALISTS FROM ALL PARTS OF THE COUNTRY—and a few other countries—discussed a wide swath of topics during a community-based HM special-interest forum at HM10. Issues that were discussed included unit-based rounding, changes to Medicare consult codes, strategies for avoiding “dumps,” and working with specialists.
Two established community hospitalists—SHM co-founders John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM—moderated the one-hour session.
Much of the debate centered on defining a hospitalist’s role and relationships with others in the hospital. One hospitalist said he’d noticed significant changes in the 15 years since he began HM practice; however, some issues remain unresolved: Primary-care physicians (PCPs) still know the patients better, and medical specialists still want hospitalists to be their “interns.”
“We have two things to sell: your expertise and your availability. It’s up to your group to determine which one you want to sell,” said Tony Lin, MD, FHM, a hospitalist and chief of the Department of Internal Medicine at Kelsey-Seybold Clinic in Houston. “I don’t think you have to pick one. So I think you have to ask yourself: What does our group want to sell to the specialist? Sometimes you might have to turn them down to make that point.”
Dr. Lin also described a phenomena emerging in the Houston area: independent, one-physician HM groups taking root in community hospitals. “A lot of the surgeons are using them because they are willing to work as the interns and residents, the first people the nurses call at 2 a.m.,” he said. “There is a market for them.”
Dr. Nelson advised community hospitalists to avoid doing “the things that make you appear different from everyone else. Build social connections with specialists; call them by their first name; eat lunch in the cafeteria; and dress professionally.”
One community hospitalist spoke of an ethical situation she regularly encounters at her hospital, which contracts with multiple HM groups. Anna Rodriguez, MD, of Chesapeake Hospitalists in Chesapeake, Va., explained that her group’s issue is acutely ill patients who are assigned to one of the other HM group services—which, unlike Dr. Rodriguez’s group, are not responsible for codes or 24/7 patient coverage. So what happens when the “other” group’s patient has a sudden deterioration and the hospital staff calls us to run the rapid response? Dr. Rodriguez asked the group.
Dr. Whitcomb suggested Dr. Rodriguez’s group, which is not contracted to run the code, work to iron that situation out. “Then, that is your job and contractually recognized,” he said.
“We get into the exact same situation in our hospital. We created a hospital medicine section and … established expectations for who responds to codes,” said Dennis Kold, MD, medical director of the hospitalist service Tri-Health in Cincinnati. “If the patient is declining, we will respond to code, but we have it set up where the expectation is that the [attending] will be in to take care of the patient in one hour, or if the patient is admitted overnight to the ICU at 10 p.m., that the [admitting] will be in the ICU to take care of the patient within four hours.” Dr. Kold added that when the attending doesn’t show up in time that penalties are enforced (e.g., taken off the ER call schedule, restriction of hospital privileges).
“If you are not dealing with rapid response, then you are just hurting yourself,” added Edward Rosenfeld, MD, a hospitalist with Lehigh Valley Medical Associates in Allentown, Pa. “You need to do it; that’s your code prevention.”
Community hospitalists also discussed bundled payments and the recent changes in Medicare consult codes. “As a hospitalist service, I want to be involved in divvying up the money,” said Dan Allen, MD, a group director in Des Moines, Iowa. “I don’t know where it’s going, but I want to have a seat at the table.”
When asked by Dr. Nelson if they had noticed a significant change in reimbursement due to Medicare’s elimination of consultation codes, few in the room raised their hands. In fact, Dr. Nelson explained, “you can bill initial hospital care instead of initial hospital consult.”
“If done right, you might get paid better,” Dr. Rosenfeld added.
Health Information Technology on the Hospitalist Radar
Health information technology (HIT) isn’t for geeks anymore. A year after a mostly tech-savvy room discussed the basics of introducing more IT aspects to HM, nearly three dozen hospitalists clamored for SHM to take advocacy positions on everything from best practices to best vendors.
“SHM could help us all speak the language we need to speak,” said Tosha Wetterneck, MD, MS, a hospitalist with the University of Wisconsin Clinic in Madison. “Visibility, transparency—give us the words.”
Participants in last year’s group focused on the technical side of IT. This year’s attendees talked about the need for SHM to create portals for shared information, message boards to spur interinstitution conversations, and, perhaps, a weekend boot-camp-style course to introduce novices to basic IT information.
“SHM needs to take a stand now,” said Damascene Kurukulasuriya, MD, FACP, CMD, CCD, a hospitalist in perioperative medicine at the University of Missouri Health System in Columbia. “We need to be part of the solution.”
To that end, Kendall Rogers, MD, assistant professor at the University of New Mexico School of Medicine and chair of SHM’s IT Task Force, says the society is making progress. More hospitalists have been encouraged to sign up for the BioMedical Informatics course at the Marine Biology Laboratory in Woods Hole, Mass. The weeklong course is an introduction to the use of computer technologies and information science related to biomedicine and health science, according to the program’s Web site (www.courses.mbl.edu/mi/). The cost of travel, housing, and meals are fully paid for by the National Library of Medicine, making the fellowship even more appealing for cash-strapped hospitals and HM groups. “It’s a hidden program,” Dr. Rogers said.
Dr. Rogers and SHM CEO Larry Wellikson have toured the country meeting with top officials from the largest IT vendors, including Cerner and GE Healthcare. An IT committee has formed, with subcommittees dedicated to policy, quality, and leadership/education. But Bob Lineberger, MD, medical information officer at Durham Regional Hospital in North Carolina, says a nuanced message will take time.
“Our focus is just coming into focus,” Dr. Lineberger conceded. “We do need to come up with a position statement.”
Education in HM: How to Grow Rock Stars and Champions
What skills does a hospitalist need to know to practice well that they didn’t learn in residency? That was the question new SHM President Jeff Weise, MD, SFHM, posed to about 20 hospitalists attending the special-interest forum on educational initiatives at HM10. Led by Dr. Wiese and SHM Education Committee co-chair Vikas Parekh, MD, FHM, the discussion focused on what SHM can do—or perhaps do better—in this capacity.
Dr. Parekh said hospitalists should be experts in quality-improvement (QI) and patient safety, and HM must incorporate that expertise into daily practice. However, he said, SHM’s largest educational focus is the new Focused Practice in Hospital Medicine pathway to American Board of Internal Medicine’s (ABIM) recertification.
In describing the future of this dynamic field, Dr. Weise raised concerns about managing the pipeline of approximately 2,500 new residents turning out each year and the potential for “losing intimacy” among SHM members—which he described as “the curse of being a champion.”
“IT is the only solution,” he added, “and identifying new and better ways of communicating.”
Competency-Based Train-ing (CBT) is critical to the development of new hospitalists, Dr. Wiese explained, as a supplement for what isn’t taught in residency. He posed a question: Should residencies last four or five years to incorporate additional training and career planning? “It’s an MBA paradigm of learning what we do,” he said. “What compels residents to join fellowship programs and earn $50K per year when they can start practicing and earning $150K?”
Educating the membership requires innovation and more than just bench-to-bedside research, Dr. Wiese added. Translational research and best-evidence practices will improve the field. “Five or 10 programs are rock stars,” he said, “but there are 377 that are terrible.”
Future SHM goals include a vision of having hospitalists hold 20% of all Internal Medicine Residency Program Director positions; developing best practices, not unfunded mandates; establishing protected academic time; and encouraging mentorship that positions hospitalists as heroes for the next generation.
An education committee sub-group has been tasked to focus on the recruitment of hospitalists and expose them to the best the society and field have to offer. HM10