Today we enjoyed an incredible President’s luncheon highlighted by the induction of the inaugural class of fellows in hospital medicine and several excellent presentations. The growth and maturation process for our specialty took another giant step forward with the introduction of this first class of fellows.
Pat Cawley did an excellent job outlining the challenges of the future including the inevitable issues of fewer physicians and less money. He suggests we need to develop yet another new paradigm for caring for patients. Dr. Cawley refers to the fact that we spend only 20-30% of our time in direct patient care as evidence that we need to redesign our present system. As hospital care accounts for more than 50% of the health care expenditure in this country, he refers to this dilemma as falling in the hospitalist’s “sweet spot”. Like it or not, we are in the center of the storm, and we should embrace the leadership role.
Larry Wellikson also presented a very informative and engaging review. Others no longer describe our profession as “the’ little engine that could”, but instead think of the hospitalist movement as “the elephant that stood up”. Larry touts the foresight of SHM in developing a strong advocacy in Washington, and predicts that this country will have a fundamentally different way we pay for healthcare before summer is out! This year! Although financing the system will require thoughtful and sometimes painful concessions, the hospitalist movement will be in the middle of reallocating funding through methods such as…dare I say it… bundling. Who among us isn’t a little concerned? However, as Larry suggests, “you have walked through the right door” when you became a hospitalist. Who better to negotiate change than the ultimate change agents of inpatient medical care? “Change is our opportunity!”
Scott Flanders kicked off his tenure as our new president with a cautionary review of the future of medicine. However Scott has maintained an “uncomfortable excitement” throughout his career as a hospitalist. Scott maintains that we will be well served by the many alliances SHM has developed.
It is clear from the presentations of these leaders that SHM is positioned to take on THE leadership role in what I refer to as the medical “econoquality” transformation.
Many of us in hospital medicine continue to struggle with program growth. Clearly as a business model, something is working for us. However, with a very limited pool of physicians to sustain this growth, we all struggle to staff appropriately. Several case studies outlining the many problems associated with our physician shortage issues were presented today. Very useful information for those in the middle of a ramp up. Working closely with all stakeholders including hospital administration, referring physicians, and even the hospital board to develop a response to the needs of the program seems obvious. However, we often overlook the importance of regular and detailed dialogue with all of these key stakeholders. In addition, increased attention to retention efforts including things such as schedule flexibility are mandatory initiatives for all programs.
As it seems this is a major topic at each and every annual meeting, I began to wonder when will hospitalists actually saturate the market? Will it occur in 5 or 10 years? In my lifetime? We now count 30 thousand among us, with high saturation of the largest hospitals. However, we are now seeing the smaller rural hospitals starting programs. When will hospitals complete this monumental transition from traditional based inpatient care to hospitalist care? As my children used to say…Are we there yet??? When are we going to get there???
I read today that millions of dollars of the ”stimulus” money was sent to dead people in error. Not only that, but some of the dead people who received their “stimulus” checks have been dead for over 8 decades. Not only that but some of these dead “octomortarians” didn’t have a social security number…ever. And not only have they been dead for 80 years, without a social security number, but they didn’t even live in this country. So, to clarify, in April I withdrew my earnings from my saving account from my little locally owned bank in the midwest and sent it to Washington so they could withdraw it from their very big but nearly insolvent bank and send it to…Italy…to a dead old guy. Or actually to many many dead old guys to the tune of millions and millions of dollars. To my way of thinking, that’s really taking redistibution of wealth to another level.
At this mornings plenary session, Dr. Chassin of the Joint Commission suggests that the health care system needs to emulate “high reliability organizations” or “HRO’s” in order to achieve high quality initiatives. In short, the big challenge of the transformation of health care will require a “focus on customer service that is very sensitive to small things that aren’t working.”
Can anybody tell me if mistaking a bunch of dead people for live ones disqualifies the government as a high reliability organization? If so, I think we can take Dr. Chassin’s presentation as an instructive review of exactly why we shouldn’t put the government in charge of our health care dollars. However, if Washington does manage to grab control of the health care pie, then I’m sure “universal health care” and “bundled payments” will be redefined in ways we can’t even imagine. Might be humorous if it wasn’t so painful.
It’s a wrap on the opening session of the annual meeting, “Hospital of the Future: Hospitalists in the C Suite”. The first hour we heard from physician CMO’s including Dr. Patrick Cawley, Dr. David Edwards and Dr. Michael Ruhlen. All hospitalists, but only Dr Cawley continues to see patients. A useful session, particularly for those interested in pursuing administrative leadership positions, but maybe even more instructive for those of us who deal with CMO’s from the “other side of the table” during negotiations.
While many gracious comments were directed toward hospitalists , including the recognition that hospitalists represent a “real time constant resource”, and are “experts in hospital work”, there also seemed to be a disconnect. Or worse, an element of disdain. Somewhat surprising considering all three panel members represent the future of physician administrators with hospital medicine backgrounds. While hospitalists were categorized as champions of quality and performance, and the importance of this work in the face of transparency and pay for performance initiatives was acknowledged, working with hospitalist leaders was labeled by Dr. Ruhlen as difficult if the hospitalist leader is like a “union shop leader”. Conflict resolution was listed by each of these CMO’s as a key skill set. I don’t recall any reference to “imagine the person you are negotiating with as a union shop steward…” anywhere in our favorite negotiating reference, “Getting To Yes”.
This touches on a very complex issue. How do we best advocate for our group, while at the same time maintaining strong relationships with administrators? While being “asked” to provide everything for the hospital system under the sun including “citizenship”, aka committee work, “surgical co-management”, aka admit H&P’s for surgeons, unassigned care, code blue service, RRT support, IT beta testing system etc… how can we as leaders avoid taking a strong stance from time to time on behalf of our group members? What I think is lost on some administrators is that if the negotiations break down to Jimmy Hoffa style tactics, then there might just be a problem that the hospital needs to take a closer look at. And maybe some time needs to be invested in listening to the trusted physician leaders in the trenches in order to forge a solution.
Dr. Eric Siegal presented a fabulous (and timely) review of the importance of developing relationships between hospitalists and administrators in his presentation, “Bringing Together Farmers and Ranchers. Bridging the Physician-Administrator Communication Gap” later in the day. Dr. Siegal highlighted the importance of mutual respect and a shared understanding of roles. Dr. Siegal suggests that these relationships must be built on a foundation of guiding principles based on the mutual interest of both parties in creating a better, safer and more efficient hospital system. Having been through many of these negotiations, I couldn’t agree more. Maybe one or two of the Physician CMO’s from the plenary session will print off the slides from Dr. Siegal’s presentation at home… so no one has to go for a swim in cement shoes.
Greetings from the largest SHM annual meeting yet, where this year we are witnessing a pilgrimage of over 1,500 hospitalists who are converging on Chicago to learn the latest in the world of hospital medicine. “The Best Practices in Managing a Hospital Medicine Program” was again a great success thanks to the excellent presentations from many of the pioneers (no Win and John, I did not say dinosaurs) of our brand of medicine.
Project BOOST is a recent SHM initiative worthy of every group’s attention. This project serves as a template for improving the transition of care for our patients. This in a time where a recent JAMA article suggests that transition of care has actually worsened for some patients over the past 10 years. It may not be a coincidence that this timeline coincides with the exponential growth of our field.
Post discharge telephone calls are a prominent feature of the project. These calls have long been advocated by John Nelson for patient satisfaction purposes. We now have data to suggest a significant reduction in 30 day readmission rates for high risk patients. Unfortunately, this reduction in readmission did not seem to persist at 60 days. We have many questions yet to answer regarding the optimal methodology for these calls, and further studies should be completed to help provide additional evidence to support this practice. How can we do it best, and what exactly can we accomplish with these calls? Further, in this environment of growing issues regarding cost containment, cost will certainly become an issue. But we are adding some science to the art of the post discharge telephone call.
Project BOOST represents an excellent and proactive opportunity for hospital medicine groups to get a handle on their transition of care process. You can access this site by visiting www.hospitalmedicine.org/BOOST