Managing Your Practice

The Global Hospitalist


 

All of the committee work that I did set the tone for these changes in my career. And that committee work included committee work in my practice, committee work at the hospital, committee work in national organizations, such as SHM and the American College of Physicians.

Born, raised, educated, and trained in the shadow of the Statue of Liberty, Nick Fitterman, MD, FACP, SFHM, is as New York as New Yorkers get. After 14 years in private practice, he “saw the handwriting on the wall” and founded a hospitalist program in the community hospital down the street. He served six years as HM group director at Huntington (N.Y.) Hospital, immersing himself in patient care and the inner workings of the health system.

Six months ago, he moved into a new, full-time administrative position as medical director of group health management for North Shore Long Island Jewish Health System, a 16-hospital system that includes 408-bed Huntington. The post is in a newly created department and focuses on “connecting parts of our healthcare system that will help serve us in the new landscape of healthcare reform as we move from individual health to population health, as we move from a model of illness to a model of wellness,” he says.

“Parts are already in our system, and my job is to link them together, help build up what needs to be built up, and to fill gaps where they exist,” he says.

Dr. Fitterman, who joined Team Hospitalist earlier this year, plans to continue working a few hospitalist shifts a month with his former group, but his new mission is clear: “Getting providers to recognize the need and the sense of urgency to redesign the way they practice medicine,” he says.

Question: What is the biggest difference between outpatient and inpatient care?

Answer: There are two significant differences. One would be the acuity of the patient. The outpatient is not as acutely ill as those in the hospital. That’s one of the things that drew me to hospital medicine. The other big difference is continuity; it is lost in the hospital. In outpatient medicine, I was able to take care of multiple generations of the same family over many years. In hospital medicine, I would only see an individual patient for three to five days.

Q: What do you like most about working as a hospitalist?

A: I enjoy the challenge of taking care of the acutely ill. An illness may be compressed into a few days, and you need to figure out quickly, and take action that has meaningful impact swiftly. I find that challenging. The other thing that I found quite challenging is the opportunity for hospitalists to help create and execute policy in the hospital that will impact the care of the whole community. As a hospitalist, you can be involved in drafting and executing policy that will impact literally tens of thousands of lives in your community. In your office, you will be more limited to the average 2,500-patient panel that an internist has.

Q: Why have you dedicated yourself to committee work?

A: I encourage any early-career physician to get involved in committees. I entered into a lot of committees … and then I broadened my committee involvement to have a better idea of all the on-goings in the hospital. It also served as a teaching vehicle, to help me understand that people are working on things just like you want to. Committee work allows you to collaborate with people who have mutual interests, instead of feeling like you’re at the end of a process and being prescribed some policy.

Q: It sounds like you’re seeing patients less and doing more what you consider “population health.” How has your experience as a hospitalist helped you in your new position?

A: All of the committee work that I did set the tone for these changes in my career. And that committee work included committee work in my practice, committee work at the hospital, committee work in national organizations, such as SHM and the American College of Physicians.

Q: When you speak about population health, what types of problems and solutions are you looking at?

A: It’s important to recognize that healthcare is only a small part of population health. Now, understanding the other side of social issues that impact our patients, you can bring to them the best healthcare possible, but if we don’t address those other needs or at least recognize them and steer them to a place where they help them with those needs, our care will not be as meaningful as we hope.

Q: Can you give an example?

A: The asthmatic who’s in your ED four times a year and gets excellent care but gets discharged home with an inability to get their medicine or to take their medicines appropriately or to reduce an environmental exposure that keeps triggering the asthmatic exacerbations. These are all the things that population health must now consider. We cannot confine ourselves simply to what we do behind closed doors of the office or within the four walls of a hospital.

Q: How much of your new job is the offspring of regulations coming down the pipe from healthcare reform?

A: Not so much because of the regulations. The changes we are seeing are driven by the market, driven by employers, and by states. Yes, the Affordable Care Act has an impact, but hopefully only to accelerate changes that we already saw taking shape. Our hope is to create a system that will provide that help to the individual and help the population to do that or reduce per-capita cost, but also by enriching the lives of providers and, of course, doing this before the regulations tell us how before someone tells us how to do it.

Q: As a former chief resident, what advice do you have for trainees entering into a new paradigm of medicine?

A: They should consider the population and not just the individual. They should consider the model wellness and not just illness to focus on in an acute-care setting. They should be trained and well-prepared. This is what hospitalist medicine does quite well: to continuously look at quality improvement and PDSA [Plan-Do-Study-Act] cycles. It should be common that they are reviewing quality metrics and planning on how they can get better as a group or even as an individual in a practice and the concept of team medicine.

Q: What is the biggest challenge hospitalists face today?

A: We need to be better versed in the change equation, how to manage change. That’s the biggest challenge.

Q: Tell me about your work with SHM. What does the society mean to you?

A: The society has really helped me understand the process in managing change, in quality-improvement cycles. Having participated in one of the mentored implementation programs [Project BOOST], I was afforded an opportunity to be coached by experts in the field. The toolkits on the SHM website I found very helpful. It was a mini-fellowship, if you will. If I didn’t take the interest that I have in SHM, I don’t think I would have either known the opportunities I have or availed myself of all the opportunities SHM can provide.

Q: What has the senior fellowship in HM meant to you?

A: It was a proud moment standing up with the first class of Senior Fellows in Hospital Medicine. We all recognize the importance of embracing the movement, recognizing the need to help lead this movement, and how we can impact the lives of hospitalist patients in our community by bringing to bear the quality initiatives, the call for focus on quality in hospital medicine that this specialty has.

Richard Quinn is a freelance writer in New Jersey.

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