I stare; a brimming audience stares back. Two eyeballs battling thousands. Slightly uncomfortable, I shift my weight, trying to hide behind the glass podium. Two microphones snake out of the podium slithering together inches from my mouth. The attendees squirm, sidle to the edge of their seats, restless to depart. HM11 is trying to close; only I stand in its way.
A Herculean task lies before me—summarize the annual meeting in a 10-minute wrap-up session titled “What We’ve Learned.” How do you summarize four days, eight pre-courses, nine breakout tracks, and more than 100 presentations in a few minutes? A bead of forehead sweat forms; I clear my throat. Memories of the past few days slide-show across my mind. It occurs to me that the essence of the meeting is not contained in the data, the information, or the PowerPoint slides that were presented. Rather, the story of HM11 is best told through its quotes.
Patient Caps: Your Grandmother and Professionalism
“I worry about patient caps because the next patient could be your grandmother.”
—Joe Li, MD, SFHM, new president of SHM
“Patient caps are the greatest threat to the professionalism of the field.”
—Rob Bessler, MD, CEO, Sound Inpatient Physicians
These two quotes from the opening plenary focused on the 2011 HM compensation and productivity survey particularly stuck out. The most noteworthy exchange came when Drs. Li and Bressler commented on the appropriate number of daily encounters for a hospitalist. The quotes highlight two important points about patient volume, especially in the wake of the training regulations that limit the number of resident physician encounters, which can engender a “cap mentality.” One is that it matters; there is a safe amount of encounters that shouldn’t routinely be breached. Two is that in the heat of the moment, Patient 19 is as important as Patient 11 and should be treated as such. Contingency plans are essential, but our field is built on the moorings of professionalism—the focus needs to be on humans, not numbers.
Hospitalist Compensation: Increasing but Not as Juicy
“It’s not going to get less anytime soon.”
In commenting on the data showing that the average community hospitalist makes about $220,000 annually—a 3% increase over last year—while producing around 4,000 work RVUs—flat over last year—and that their academic counterparts made $173,000 on about 3,400 wRVUs, Dr. Bressler opined that the laws of supply and demand would dictate that salaries would continue to rise for the near term. Although I agree with Dr. Bressler, my guess is that future salary increases will be driven more by quality than quantity (more to follow below).
—John Nelson, MD, MHM, SHM cofounder
Dr. Nelson highlighted interesting data showing that the average pay per wRVU was approximately $54. However, he noted that the compensation per wRVU tends to peak at a certain level, after which compensation per wRVU falls. In other words, after, say, 4,000 wRVUs, the amount of compensation per wRVU diminishes such that seeing more patients benefits an individual hospitalist less. That is, lots of squeeze, little juice at the high end.
Reform: Variety, Change, and Waste
“Variety is about choice; change is not.”
—Cecil Wilson, MD, AMA president
“You won’t have many more conferences where you start by talking about work RVUs.”
—Bob Kocher, MD, former special assistant to President Obama
The highlight of the conference for me was Dr. Kocher’s behind-the-scenes look at what was a very publicly muddy event—the passage of ACA. Coming from a D.C. insider, this under-the-covers peek at the machinations that went into passing the healthcare reform bill was fascinating.
The key message, summarized in this comment referring to the opening plenary about hospitalist compensation and productivity, was that the future is quality and the future is now. In the very near future, we will be measured and paid based on our ability to effect quality outcomes, not patient encounters. The message was simple: It’s about quality, not quantity.
“It costs $7.50 for a healthcare transaction, versus 2 cents for a VISA transaction.”
A statistic I had not heard before, this quote sums up one of the major problems with American healthcare: waste. The $7.50 transaction he was referring to was the amount of money it takes to file a healthcare claim. We certainly feel it in the challenges of documentation, billing, and denials, but the system feels it in terms of high cost of capturing what in many ways should be as simple as swiping your credit card at Starbucks.
Duty-Hour Restrictions: Harbinger of The Future?
“Don’t begrudge the ACGME—begrudge us.”
—Jeff Wiese, MD, SFHM, SHM past president
In a much-anticipated session on the impact of the new ACGME residency work-hour rules commencing in July—notably limiting intern (16-hour) and resident (28-hour) shift duration—Dr. Wiese aptly pointed out that a lot of the angst toward residency work environment regulation could have been avoided if physician leadership had better reacted to the issues of sleep deprivation and resident fatigue following Libby Zion’s death in 1984. Had we put our energy into improving work conditions rather than debate the impact of sleep deprivation on the outcome in this one case, we might be in a different place today.
I couldn’t help but wonder if the message here could also be applied to society’s push for higher quality, lower cost, and safer care. Either we regulate ourselves or someone else will. In other words, we need to embrace quality and safety, or it will be thrust upon us from external sources in ways we might not like.
A Mariner Calls
“I love you, Papi. Come home and take some baseball cuts.”
—Greyson Glasheen, future Major League Baseball shortstop
I wrote in a column leading up to the annual meeting (see “Annual Meeting Mariner,” April 2011, p. 45) that I was looking forward to the meeting because it was a professional mariner of sorts, a way for me to refresh, reset, and reinvigorate. Indeed, reflecting from the podium, it had been a fantastic meeting that served its purpose well. I had learned a ton, caught up with colleagues I hadn’t seen since the last meeting, saw old medical school friends, and met future old friends. I’d led a committee, given a talk, presented a poster, met up with a mentor, and had a reunion with past attendees of the Academic Hospitalist Academy.
Yet I was ready to get back to normalcy. On the last night of the meeting, I was therefore drawn by a different, more personal mariner—this time, a 14-second voicemail message from a 3-year-old boy waiting impatiently for Dad to come home, to make him his center, to simply play a little tee ball in the backyard. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado at 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.