March 2019 HOSPITALIST TRENDS HM 2019 IN THE LITERATURE Volume 23 No. 3 Telemedicine is “ripe Focus is developing HAI rates are going p8 for adoption” p10 clinical mastery p20 down PREVIEW

Lou Ferraro/Park South PhotograPhy Crafting a ‘well-rounded’ program New tracks, interactive programs highlight HM19

By Larry Beresford committee members for their vote. So many great topics were proposed for HM19, with so many great faculty, that we s course director for the Society of Medi- had to make hard choices – although we see that as a good Acine’s 2019 annual conference – Hospital 2019 problem. It was my job to make sure that we had a process (HM19) – to be held March 24-27 in National Harbor, that works,” Dr. Smith explained. “We have planned what Md., Dustin T. Smith, MD, SFHM, hospitalist and associate we believe will be another well-attended and well-received professor of medicine at Emory University, Atlanta, tried conference. Every year it’s been great, but his best to apply democratic processes to the work of the every year we try something to make it a little better.” annual conference committee. The SHM annual conference committee meets in person ® “We created numerous email surveys to go out to the 20 Continued on page 14 the-hospitalist.org

SURVEY INSIGHTS PRACTICE MANAGEMENT Amanda T. Trask, John Nelson,

MBA, MHA, SFHM MD, MHM

Hospitalist scheduling: The past and future of

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CHANGE SERVICE REQUESTED SERVICE CHANGE Presorted Standard Standard Presorted THE HOSPITALIST THE CAREER NEWS March 2019 Volume 23 No. 3 Hospitalist PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Danielle B. Scheurer, MD, SFHM, MSCR; Phone: 800-843-3360 Movers and Shakers [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org By Matt Pesyna ty as the new campus dean in the PEDIATRIC EDITOR Laurence Wellikson, MD, MHM, CEO Weijen Chang, MD, FACP, SFHM Joplin (Mo.) College of Osteopathic Vice President of Marketing & [email protected] Communications Flora Kisuule, MD, SFHM, has been Medicine. COORDINATING EDITORS Lisa Zoks Dr. Rosch is a awarded the 2018 Excellence in Ser- Dennis Chang, MD [email protected] vice and Profes- practicing hospi- The FuTure hospiTalisT Marketing Communications Manager sionalism Award talist in Illinois, Brett Radler Jonathan Pell, MD [email protected] Key CliniCal Guidelines by Johns Hopkins where she was Marketing Communications Specialist Bayview Medical chair of internal CONTRIBUTING WRITERS Felicia Steele Center, Baltimore. medicine at the Larry Beresford [email protected] Dr. Kisuule is as- Chicago College Suzanne Bopp SHM BOARD OF DIRECTORS President sociate director of Osteopathic Talya Bordin-Wosk, MD Constance Chace, MD, MPH Nasim Afsar, MD, SFHM of the division of Dr. Rosch Medicine. Sara Freeman President-Elect hospital medicine Jeydith Gutierrez, MD Christopher Frost, MD, SFHM Treasurer Bryan Huang, MD, FHM Dr. Kisuule at Johns Hopkins Suzan Lowry, MD, has been named Danielle Scheurer, MD, MSRC, SFHM Peter J. Kaboli, MD, MS Bayview, assistant health officer for Charles County, Md., Secretary Tracy Cardin, ACNP-BC, SFHM Jonathan McIntyre, MD professor at Johns Hopkins Univer- by the county Department of Health Immediate Past President John Nelson, MD, MHM Ron Greeno, MD, FCCP, MHM sity School of Medicine, and assis- and Charles County Commissioners. Matt Pesyna Steven B. Deitelzweig, MD, MMM, FACC, tant professor in the Johns Hopkins A longtime pediatrician with 20 years’ Luann Tammany, PT, MBA FACP, SFHM Amanda Trask, MBA, MHA, SFHM Bloomberg School of . experience, Dr. Lowry has served as Howard R. Epstein, MD, SFHM Nhan Vuong, MD Kris Rehm, MD, SFHM Dr. Kisuule codeveloped a hospi- a pediatric hospitalist educator at FRONTLINE MEDICAL Bradley Sharpe, MD, FACP, SFHM Jerome C. Siy, MD, SFHM talist fellowship program for Johns Children’s National Medical Center in COMMUNICATIONS EDITORIAL STAFF Hopkins University, and has served Washington. Rachel Thompson, MD, MPH, SFHM Editor in Chief Mary Jo M. Dales Patrick Torcson, MD, MMM, SFHM on several SHM committees and Dr. Lowry has spent most of her Executive Editors Denise Fulton, Kathy Scarbeck FRONTLINE MEDICAL consulted on hospitalist programs career working on behalf of public COMMUNICATIONS ADVERTISING STAFF Editor Richard Pizzi VP/Group Publisher; Director, around the world. Dr. Kisuule is join- health. Most recently, she has worked Creative Director Louise A. Koenig FMC Society Partners ing the SHM Board of Directors in at the U.S. Marine Corps Quantico Director, Production/Manufacturing Mark Branca March 2019. Health Clinic in Virginia. Rebecca Slebodnik National Account Managers EDITORIAL ADVISORY BOARD Valerie Bednarz, 973-206-8954 Paul Hain, DO, was promoted recent- Robyn Chase, DO, a staff hospitalist Geeta Arora, MD; Michael J. Beck, MD; cell 973-907-0230 [email protected] ly to chief medical officer and senior at Yavapai Regional Medical Center Harry Cho, MD; Marina S. Farah, MD, Artie Krivopal, 973-206-8218 MHA; Stella Fitzgibbons, MD, FACP, cell 973-202-5402 [email protected] vice president of (Prescott, Ariz.), recently was selected FHM; Benjamin Frizner, MD, FHM; Classified Sales Representative market delivery as the hospital’s Physician of the Year Nicolas Houghton, DNP, RN, ACNP-BC; Heather Gonroski, 973-290-8259 for Blue Cross/ for 2018. James Kim, MD; Melody Msiska, MD; [email protected] Linda Wilson, 973-290-8243 Blue Shield of Dr. Chase has practiced at YRMC Venkataraman Palabindala, MD, SFHM; Raj Sehgal, MD, FHM; Rehaan Shaffie, [email protected] . Dr. Hain has since 2010. She also serves as an as- MD; Kranthi Sitammagari, MD; Senior Director of Classified Sales a wealth of experi- sociate professor at the University of Amith Skandhan, MD, FHM; Tim LaPella, 484-921-5001 ence in leadership, Arizona, Phoenix. Lonika Sood, MD, FACP, FHM; cell 610-506-3474 [email protected] including helping Amanda T. Trask, MBA, MHA, SFHM; Advertising Offices 7 Century Drive, Amit Vashist, MD, FACP; Suite 302, Parsippany, NJ 07054-4609 create the pediat- Kevin Dishman, MD, has been ele- Jill Waldman, MD, SFHM 973-206-3434, fax 973-206-9378 Dr. Hain ric hospitalist pro- vated to senior vice president and gram at Vanderbilt chief medical officer at Stormont THE HOSPITALIST is the official newspaper of the Society THE HOSPITALIST (ISSN 1553-085X) is published monthly Children’s Hospital in Nashville, Tenn. Vail Health (Topeka, Kan.). Dr. of Hospital Medicine, reporting on issues and trends in for the Society of Hospital Medicine by Frontline Medical With BC/BS, Dr. Hain will oversee Dishman also will be president of hospital medicine. THE HOSPITALIST reaches more than Communications Inc., 7 Century Drive, Suite 302, Par- the region’s public relations, com- Stormont medical services division’s 35,000 hospitalists, physician assistants, nurse practitioners, sippany, NJ 07054-4609. Print subscriptions are free for medical residents, and health care administrators interested Society of Hospital Medicine members. Annual paid sub- munity investments, medical staff. in the practice and business of hospital medicine. Content scriptions are available to all others for the following rates: relations, and lobbying. Dr. Dishman came to Stormont in for THE HOSPITALIST is provided by Frontline Medical Individual: Domestic – $184 (One Year), $343 (Two Years), 2000 to work as a hospitalist. Most Communications. 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By Amanda T. Trask, MBA, Secondly, ensuring that the hos- sicians (57.4%). Thirdly, was use of MHA, SFHM pitalist team is right sized – that is, locum tenens physicians. scheduling hospitalists in the right With these baselines, we will be cheduling. Has there ever place at the right time – is an art. able to better track and trend the been such a simple word Using resources, such as the 2018 industry going forward. that is so complex? A simple Internet search of hospitalist Scheduling methodologies Sscheduling returns thousands of For HMGs serving adults only, 7 on/7 possible discussions, leaving readers off remains the preferred scheduling to conclude that the possibilities are method (56% of groups). This is high- endless and the challenges great. er than in the 2016 survey (38%), but it The answer certainly is not a one- SoHM report, to identify quantifi- is probably related to year-over-year size-fits-all approach. able comparisons enables hospitalist differences in the mix of survey re- Hospitalist scheduling is one of groups to continuously ensure the spondents as opposed to a significant the key sections in the 2018 State of hospitalist schedule meets the clin- change in how groups are scheduling. Hospital Medicine (SoHM) report; the ical demands while optimizing the For pediatric practices, the fixed Ms. Trask is national vice president 2018 report delves deeper into hospi- hospitalist group’s schedule. rotating block scheduling has de- of the Hospital Medicine Service talist scheduling than ever before. creased over the two survey periods Line at Catholic Health Initiatives Unfilled positions (16.7% versus 6.7%). in Englewood, Colo. She is also a The 2018 SoHM report Even though the 7-on/7-off sched- member of SHM’s Practice Analysis features a new section on ule remains quite popular among Committee. unfilled positions that may adult-only HMGs, many seasoned provide insight and bet- hospitalists wonder whether this is nico_blue/Getty Images ter understanding about sustainable through all seasons of dedicated daytime admitter. how your group compares life. Some hospitalists have said a remain in demand! to others, as it relates to 7-on/7-off schedule is like turning on Over 80% of adult hospitalist groups 7 on/7 off is the preferred properly evaluating your and off your personal life and that have on-site hospitalists at night. recruitment pipeline. it takes a day or 2 to recover from 7 About a quarter of pediatric-only scheduling method for For hospital medicine consecutive 12-hour days. practices have nocturnists. groups (HMGs) serving On the other hand, a fixed sched- 56% of HMGs that adults only, two out of ule is the easiest to explain, and Scheduled workload distribution three groups have unfilled many new hospitalists are request- One way of scheduling as- serve adults. positions, and about half of ing a fixed schedule. Even so, a fixed signments is the phenomenon of ews pediatric-only hospitalist schedule may not allow for enough unit-based assignments, or geograph- ge N groups have unfilled posi- flexibility to adapt the schedule to ic rounding. As this has become more

MD e D tions. Andrew White, MD, the demands of patient care. prevalent, the SHM Practice Analysis SFHM, associate professor Nonetheless, a fixed schedule Committee recommended adding a Source: Society of Hospital Medicine’s 2018 State of of medicine at the Univer- remains a very popular scheduling question about unit-based assign- Hospital Medicine Report sity of Washington, Seattle, pattern. Does this scheduling model ments to the 2018 SoHM report. provided us with a deep- lead to burnout? Does this schedul- The adoption of unit-based assign- For those of you who have been dive discussion of this topic in a recent ing model increase or decrease elas- ments is higher in academic groups regular users of prior SoHM reports, article in The Hospitalist. ticity? The debate of flexible versus (54.3%), as well as among hospitalists you should be pleasantly surprised If your group has historically had fixed schedules continues! employed at a “hospital, to find new comparative values: more unfilled positions than the or integrated delivery system” (47.4%), There are nearly 50% more pages respondents, it might mean your Results by shift type than in other group practice models. dedicated just to scheduling! group should consider different Very simply, the length of individual Just as with the presence of day- For those readers who have never strategies to close the gap. It may shifts has not changed much in prior time admitters, the larger the group subscribed to the SoHM Report, also lead to conversations about years. For adult-only practices, most the more likely it has some form of this is your chance to study how how to rethink the schedule to bet- all day and night shifts are 12 hours in unit-based assignments. Further other groups approach schedules. ter meet the demands of clinical length. For pediatric-only HMGs, most study would be needed to determine Why is hospitalist scheduling such care with limited resources. day shifts are about 10 hours, and whether there is a link between the a hot topic? For one, flexible and So, with all these unfilled positions, most night shifts are about 13 hours. presence of daytime admitters and sustainable scheduling is an import- how are hospitalist groups filling the Most evening or swing shifts for successful unit-based assignments ant contributor to job satisfaction. It gap? Not all groups are using locum adult-only practices are about 10 for daytime rounders. is important for hospitalists to have tenens to fill those unfilled positions. hours, which is a slight decrease from a high degree of input into manag- About a third of hospitalist groups re- 2016. Pediatric-only practices’ evening What’s the verdict? ing and effecting change for person- ported leaving those gaps uncovered. shifts are about 8 hours in length. Hospitalist scheduling is a nev- al work-life balance. The most commonly reported tac- A new question this year is about er-ending balance of what’s best for As John Nelson, MD, MHM, a co- tic to fill in the gaps was voluntary daytime admitters. For adult hos- patients and what’s best for hospi- founder of the Society of Hospital extra shifts by existing hospitalists pitalist groups, over half of groups talists and other key stakeholders. Medicine, wrote recently in The Hos- (physicians and/or nurse praction- have daytime admitters. For pedi- Scheduling is personal. Scheduling pitalist, “an optimal schedule alone ers/physician assistants). This ap- atric groups, nearly three out of is an art form. Has anyone figured isn’t the key to preventing it [burn- proach is used by 70% of hospitalist four groups have daytime dedicated out the “secret sauce” to hospitalist out], but maybe a good schedule can groups. The second most-used tactic admitters. Also, the larger the group scheduling? Go online to SHM’s reduce your risk you’ll suffer from it.” was “moonlighters” or p.r.n. phy- size, the more likely it is to have a HMX to start the discussion! the-hospitalist.org | 7 | March 2019 ANALYSIS Is a telehospitalist service right for you and your group? Telemedicine “ripe for adoption” by hospitalists

By Peter J. Kaboli, MD, MS, where lower acuity ICU patients would be to international areas in and Jeydith Gutierrez, MD could remain in the small, rural ICU, need of hospitalist expertise, like a and only those patients who the in- medical mission model but without or medical inpatients, the ad- tensivist believes would benefit from the expense or time required to travel. vent of virtual care began de- a higher level of care in a tertiary cen- Other models will likely evolve based cades ago with telephones and ter would be transferred. on the demand for services, supply of the ability of physicians to give As this study and others have hospitalists, changes in regulations, F“verbal orders” while outside the hos- shown, telemedicine is ripe for and reimbursement. pital. It evolved into widespread adop- adoption by hospitalists. The bigger Another important consideration Dr. Kaboli Dr. Gutierrez tion of pagers and is now ubiquitous question is how should it fit into the is how this will evolve for the prac- through smart phones, texting, and current model of hospital medicine? ticing hospitalist. Will we have dedi- Dr. Kaboli and Dr. Gutierrez are HIPPA-compliant applications. In the There are several different applica- cated virtual hospitalists, akin to the based at the Center for Access past few years, inpatient telemedicine tions we are familiar with and each “” who covers nights and and Delivery Research and programs have been developed and has unique considerations. The first weekends? Or will working on the Evaluation (CADRE) at the Iowa studied including tele-ICU, telestroke, model, as applied in the Kuperman telehospitalist service be in the ro- City VA Healthcare System, the and now the telehospitalist. paper, is for a larger hospitalist pro- tation of duties like many programs Veterans Rural Health Resource Telemedicine is not new and has gram to provide a telehospitalist ser- have with teaching and “nonteaching” Center-Iowa City, VA Office of seen rapid adoption in the outpatient vice to a smaller, unaffiliated hospital services, medical consultation, and Rural Health, and the department setting over the past decade,1 especial- (for example, critical access hospitals) even transition clinics and emergency of internal medicine, University of ly since the passing of telemedicine that employs nurse practitioners or department triage responsibilities? Iowa, both in Iowa City. parity laws in 35 states to support physician assistants on site but can’t For any of these models to work, equal reimbursement with face-to- recruit or retain full-time hospitalist technical aspects must be ironed out. face visits.2 In addition, 24 states have coverage. In this collaborative model It is indispensable for the provider to work as a hospitalist regardless of joined the Interstate Medical Licen- of care, the local provider performs have remote access to the electronic where they live or where the hospital sure Compact (IMLC).3 This voluntary the physical exam but provides care health record for data review, docu- is located. program provides an expedited path- under the guidance and supervision mentation, and placing orders if need- Second, the telehospitalist model way to licensure for qualified physi- of a hospital medicine specialist. This ed. Adequate broadband for effective will require professional standards, cians who practice in multiple states. is expected to improve outcomes and video connection, accompanied by the training, reimbursement and coding The goal is to increase access to care bring the benefits of hospital medi- appropriate HIPPA-compliant soft- adjustments, hardware and software for patients in underserved and rural cine, including improved outcomes ware and hardware must be in place. development, and managing patient areas and to allow easier consultation and decreased hospital spending, to Based upon prior experience with expectations for care. through telemedicine. Combined, smaller communities.6 In this model, telemedicine programs, establishment Lastly, hospitals, health care sys- these two federal initiatives have the critical access hospital pays a fee of trusting relationships with the re- tems, hospitalist groups, and even lowered two major barriers to entry for the service and retains the billing ceiving hospital staff, physicians, and individual hospitalists will have to for telemedicine: reimbursement and to third-party payers. nurse practitioners is also critical. Op- determine how best to take advantage credentialing. A variation on that model would timally, the telehospitalist would have of this innovative model of care to Only a handful of papers have provide telehospitalist services to an opportunity to travel to the remote provide the highest possible quality, been published on the telehospitalist other hospitals within an existing site to meet with the local care team in a cost-efficient manner, that sup- model with one of the first in 2007 health care network (such as Kaiser and learn about the local resources ports professional satisfaction and in The Hospitalist reporting on the Permanente, Intermountain Health- and community. Many other oper- development. intersection between tele-ICU and care, government hospitals) that have ational and logistical issues need to telehospitalist care.4 More recent different financial models with in- be considered and will be supported References work describes the implementation centives to collaborate. The Veterans by the Society of Hospital Medicine 1. Barnett ML et al. Trends in telemedicine use in a of a telehospitalist program between Health Administration is embarking through publications, online resourc- large commercially insured population, 2005-2017. a large university hospitalist program on a pilot through the VA Office of es, and national and regional meeting JAMA. 2018;320(20):2147-9. and a rural, critical access hospital.5 A Rural Health to provide a telehospital- educational content on telehospitalist 2. American Telemedicine Association State Policy Resource Center. 2018; http://www.american- key goal of this program, developed ist service to small rural VA hospitals programs. telemed.org/main/policy-page/state-policy-re- by Ethan Kuperman, MD, and col- using the consultative model during As hospital medicine adopts the source-center. Accessed 2018 Dec 14. leagues at the University of Iowa, was the day with a nurse practitioner at telehospitalist model, it brings with 3. Interstate Medical Licensure Compact 2018; to keep patients at the critical access the local site and physician backup it important considerations. First is https://imlcc.org/. Accessed 2018 Dec 14. hospital that previously would have from the . Al- how we embrace the concept of the 4. Hengehold D. The telehospitalist. The Hospi- talist. 2007;7(Jul). https://www.the-hospitalist. been transferred. This has obvious though existing night cross-coverage medical virtualist, a term used to org/hospitalist/article/123381/telehospitalist. benefits for patients, the critical ac- will be maintained by a physician on describe physicians who spend the Accessed 2018 Dec 14. cess hospital, and the local communi- call, this telehospitalist service may majority or all of their time caring for 5. Kuperman EF et al. The virtual hospitalist: A ty. It also benefited the tertiary care also evolve into providing cross-cover- patients using a virtual medium.7 We single-site implementation bringing hospitalist coverage to critical access hospitals. J Hosp Med. referral center, which was dealing age on nights and weekends. find it difficult to imagine spending 2018;13(11):759-63. with high occupancy rates. Keeping A third would be like a locum ten- all or the majority of our time as a vir- 6. Peterson MC. A systematic review of outcomes lower acuity patients at the critical ens model in which telehospitalist tual hospitalist, but years ago many and quality measures in adult patients cared for access hospital helps maintain access services are contracted for short peri- could not imagine someone being a by hospitalists vs nonhospitalists. Mayo Clinic proceedings. 2009;84(3):248-54. for more complex patients at the ods of time when coverage is needed full-time hospitalist or nocturnist. 7. Nochomovitz M, Sharma R. Is it time for a new referral center. This same principle for vacations or staff shortages. A Some individuals will see this as a ca- medical specialty?: The medical virtualist. JAMA. has applied to the use of the tele-ICU fourth model of telehospitalist care reer opportunity that allows them to 2018;319(5):437-8. March 2019 | 8 | The Hospitalist nvested

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HOSP_9.indd 1 2/20/2019 11:43:22 AM PREVIEW Developing clinical mastery at HM19 Boosting your bedside diagnostic skills

By Larry Beresford POCUS is a new technology that is not yet in tool of choice. But when looking for fluid around wide use at the hospital bedside, but clearly a the heart or ascites buildup in the abdomen or new three-session minitrack devoted to the wave is building, said Dr. Dancel’s copresenter, when looking at the heart itself, she said, there is A clinical mastery of diagnostic and treatment Michael Janjigian, MD, associate professor in the no better tool at the bedside than ultrasound. skills at the hospitalized patient’s bedside department of medicine at NYU Langone Health In January 2019, the SHM issued a position should be a highlight of the Society of Hospital in . statement on POCUS,1 which is intended to in- Medicine’s 2019 annual conference. form hospitalists about the technology and its The “Clinical Mastery” track is designed to help uses, encourage them to be more integrally in- hospitalists enhance their skills in making expert volved in decision making processes surrounding diagnoses at the bedside, said Dustin T. Smith, POCUS program management for their hospitals, MD, SFHM, course director for HM19, and asso- and promote development of standards for hos- ciate professor of medicine at Emory University, pitalists in POCUS training and assessment. The Atlanta. “We feel that all of the didactic sessions SHM has also developed a pathway to teach the offered at HM19 are highly useful for hospitalists, use of ultrasound, the Point-of-Care Ultrasound but there is growing interest in having sessions Certificate of Completion. devoted to learning clinical pearls that can aid in Dr. Smith Dr. Dancel Dr. Janjigian In order to qualify, clinicians complete online practicing medicine and acquiring the skill set of training modules, attend two live learning cours- a master clinician.” “We’re at the inflection point where the cost es, compile a portfolio of ultrasound video clips The three clinical mastery sessions at HM19 of the machine and the availability of training on the job that are reviewed by a panel of ex- will address neurologic symptoms, ECG interpre- means that hospitals need to decide if it’s time to perts, and then pass a final exam. The exam will tation, and the role of point-of-care ultrasound embrace it,” he said. Hospitalists may also consid- be offered at HM19 for clinicians who have com- (POCUS), currently a hot topic in hospital medi- er petitioning their hospital’s leadership to offer pleted preliminary work for this new certificate cine. Recent advances in ultrasound technology the machines and training. – as well as precourses devoted to ultrasound have resulted in probes that can cost as little as “Hospitalists’ competencies and strengths lie and other procedures – and another workshop $2,000, fit inside a lab coat pocket, and be read primarily in making diagnoses,” Dr. Janjigian on POCUS. from a smartphone – making ultrasound far easi- said. “We like to think of ourselves as master Earning the POCUS certificate of completion er to bring to the bedside of hospitalized patients, diagnosticians. Our session at HM19 will explore requires a lot of effort, Dr. Dancel acknowledged. said Ria Dancel, MD, FHM, associate professor of the strengths and weaknesses of both the physi- “It is a big commitment, and we don’t want hos- internal medicine and pediatrics at the University cal exam and POCUS, presenting clinical scenar- pitalists thinking that just because they have of North Carolina at Chapel Hill. ios common to hospital medicine. This course is completed the certificate that they have fully Dr. Dancel will copresent the POCUS clinical designed for those who have never picked up an mastered ultrasound. We encourage hospitalists mastery track at HM19. “Our focus will be on ultrasound probe and want to better understand to find a proctor in their own hospitals and to how POCUS and the physical exam relate to each why they should, and for those who want a work with them to continue to refine their skills.” other. These are not competing technologies better sense of how they might integrate it into Dr. Dancel and Dr. Janjigian reported no rele- but complementary, reflecting the evolution in their practice.” vant disclosures. bedside medicine. Because these new devices While radiology and cardiology have been using will soon be in the pockets of your colleagues, ultrasound for decades, internists are finding Reference residents, physician assistants, and others, you uses at the bedside to speed diagnosis or focus 1. Soni NJ et al. Point-of-care ultrasound for hospitalists: A posi- should at least have the knowledge and vocabu- their next diagnostic steps, Dr. Dancel noted. For tion statement of the Society of Hospital Medicine. J Hosp Med. lary to communicate with them,” she said. certain diagnoses, the physical exam is still the 2019 Jan 2. doi: 10.12788/jhm.3079. The power of policy at HM19

By Suzanne Bopp affect hospitalists, said Josh Boswell, back to back. “Both sessions are for Quality Measurement and Val- director of government relations at designed to give attendees an entrée ue-Based Incentives Group in the s a result of to the steadily SHM. into health policy and explain devel- Centers for Clinical Standards and Agrowing interest of SHM mem- “Many of the policy developments opments that are happening right Quality at the Centers for bers in health care policy and in D.C. are directly impacting our now in Washington that impact their & Services. Dr. Duseja advocacy issues, the 2019 Annual members’ practices,” he said. “A cou- practice,” said Joshua Lapps, govern- oversees the development of mea- Conference will include a mini-track ple of years ago, it was decided to add ment relations manager at SHM. sures and analyses for a variety dedicated to policy issues. a specific track at the annual confer- The first session – “CMS Policy of CMS quality reporting and val- To be held on Monday, March 25th ence to cover some of these policy Update: An Overview of Meaningful ue-based purchasing programs. She at HM19 in National Harbor, Md., the issues, and we’ve generally had posi- Measures and the Quality Payment is also an phy- health care policy mini-track will up- tive feedback on the sessions.” Program” – will take place from 2:00 sician and was an associate profes- date conference attendees on some of This year, the mini-track will con- to 3:30 p.m., and will feature Reena sor at the University of California, the Washington developments that sist of two separate sessions, held Duseja, MD, MS, the acting director Continued on page 12 March 2019 | 10 | The Hospitalist When Hospitalists and EM docs share ownership we all breathe a little easier.

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HOSP_11.indd 1 1/23/2019 2:20:24 PM HM19 PREVIEW How to address gender bias in research funding

By Sara Freeman might be influencing the gender gap. lect robust evidence on the success of grant “Women are scored lower for competence com- applications and be transparent who is getting LONDON – Female investigators are less likely to pared to men with the same publication record,” funded and how much funding is being awarded. secure research funding than male investigators, she said. It’s not that they publish less or do Institutions should invest in and support young not because their proposed project is of lesser sci- easier research, or that the quality is lower; they investigators, distributing power and flattening entific merit, but simply because they are women, are just viewed less favorably overall throughout traditionally male-led hierarchies. Salaries should according to research published in The Lancet. their careers. Even when you be aligned and research support evened out, she Women had a 30% lower chance of success in control for confounding fac- said. getting funding for a project than did their male tors, “they still don’t advance as Investigators themselves also have a role to counterparts when the caliber of the principal quickly,” she said. play to do the best possible work and try to investigator was considered as an explicit part of “It had been documented for change the system. “Advocate for others,” she the grant application process, with an 8.8% proba- a while that, overall, women said. That included advocating for others in bility of getting funded versus 12.7%, respectively. tend to get less grant funding groups that you may not be part of – which can If the application was considered solely on a proj- and there hasn’t been any be easier in some respects than advocating for a ect basis, however, the gender bias was less (12.1% evidence to show either way group that you are in. vs. 12.9%). Dr. Witteman if maybe women’s grant appli- “Funders should evaluate projects, not people,” The overall success of grant applications was cations weren’t as good,” Dr. Jennifer L. Raymond, PhD, and Miriam B. Good- 15.8% in the analysis, which considered almost Witteman explained. man, PhD, both professors at Stanford (Calif.) 24,000 grant applications from more than 7,000 In 2014, the CIHR changed the way it funded University wrote in a comment in The Lancet principal investigators submitted to the Canadian research projects, creating a “natural experiment.” special issue. They suggested that people-based Institutes of Health Research (CIHR) between Two new grant application programs were put in funding had been gaining popularity but that 2011 and 2016. place which largely differed by whether or not an funders would be better off funding by project to “I see our study as basically one good thwack in explicit review of the principal investigator and achieve scientific and clinical goals. “Assess the a long game of whack-a-mole,” lead study author their ability to conduct the research was included. investigator only after double-blind review of the Holly O. Witteman, PhD, said. Adjusting for age and type of research, Dr. proposed research is complete,” they suggested. Dr. Witteman’s research was included in a the- Witteman and her coauthors found that there “Reduce the assessment of the investigator to a matic issue of The Lancet that brings together was little difference in the success of women in binary judgment of whether or not the investiga- female authors and commentators to look at gen- securing research funding when their grant ap- tor has the expertise and resources needed do the der equity and what needs to be done to address plications were judged solely on a scientific basis; proposed research.” imbalances. however, when the focus was placed on the prin- Cassidy R. Sugimoto, PhD, associate professor That there are discrepancies in research fund- cipal investigator, women were disadvantaged. of informatics at Indiana University in Bloom- ing awarded to female and male investigators Dr. Witteman said that “this provides robust ington and a program director for the Science has been known for years, Dr. Witteman, associ- evidence in support of the idea that women write and Innovation Policy Program at the National ate professor of family and emergency medicine equally good grant applications but aren’t evalu- Science Foundation (NSF) observed that data on at Laval University, Quebec City, said. To learn ated as being equally good scientists.” gender equality in research funding were already how and why, the researchers used a “quasiex- So how to redress the balance? Dr. Witteman being collected and will be used to determine how perimental” approach to find out what factors suggested that one way was for funders to col- best to adjust funding policies.

Continued from page 10 with an overview of the Quali- a presentation by Jennifer Bell, vision behind quality measures and San Francisco, in the department of ty Payment Program under the founding partner at Chamber Hill quality measurement. This is a real- emergency medicine, where she led Medicare Access and CHIP Reau- Strategies, who represents SHM ly exciting opportunity to hear from quality improvement activities. thorization Act of 2015 (MACRA), in Washington. “Jennifer will be someone who is both a clinician and “The session with Dr. Duseja will specifically highlighting policy discussing how Washington works, works on policy at CMS.” be an inside look into the approach changes from 2018 to 2019 to the the policy process and the pres- The policy mini-track offers hos- that CMS is taking for quality mea- Merit-Based Incentive Payment sure points at which SHM and its pitalists a chance to get a look “be- surement and pay-for-performance System (MIPS) and Meaningful members can exert influence,” Mr. hind the curtain” at policy making programs, specifically looking at the Measures Initiative. Attendees will Lapps said. from someone who is helping to quality payment program which learn more about CMS’s approach Attendees can expect to learn a write the rules. came out of the Medicare Access and to quality and quality measure- lot from either session, Mr. Lapps “Attendees will gain insight on Chip Reauthorization Act,” Mr. Lapps ment, as well as the future of qual- said. “Attendees will learn about where they fit in these programs said. “It will be a high-level discus- ity reporting programs. the basic contours of the Quality – and also have the opportunity to sion about how the programs affect Following Dr. Duseja’s presentation, Payment Program that Medicare tell Dr. Duseja if they don’t feel these hospitalists, and how hospitalists the second mini-track session will oversees, and some of the specific programs are a good fit for them,” participate in the programs. It’s also a take place from 3:40 to 4:25 p.m. It will new elements of that program this Mr. Boswell said. “Oftentimes these chance for attendees to hear some of focus more intently on the processes year that were designed with hos- programs are not structured ideally the thinking inside CMS.” around health care policy making. pitalists in mind. For example, Dr. for hospitalists. So, hearing directly Dr. Duseja is also hoping to get “We heard from our members who Duseja will be talking about a facil- from hospitalists who are experi- feedback from HM19 attendees. “She attended this mini-track at the past ity-based reporting option under encing problems would be extraor- wants the session to be educational two annual conferences that they the Merit-Based Incentive Payment dinarily helpful to a CMS official. for our members, as well as an op- would like us to explain how policy System. I think our members should I think attendees should view the portunity for her to learn from hos- making works: the play-by-play in gain a concrete understanding of policy track not only as an oppor- pitalists,” Mr. Lapps said. D.C. on how we get to where we are,” some of the new directions that tunity to learn from CMS, but as an According to Dr. Duseja, her pre- Mr. Boswell said. CMS is heading this year. Overall, opportunity to educate CMS about sentation will provide attendees The second session will feature they’ll have a better sense of the our issues.” March 2019 | 12 | The Hospitalist HM19 PREVIEW Learning from the Storytelling can inform medical practice

By Larry Beresford ancient Greek physician, Galen (129- 200 AD), who directed the celebrated ach year the Society of Hospital Asclepeion or hospital in Pergamon EMedicine’s Annual Conference (present-day Bergama, Turkey). This Committee examines prior ancient hospital’s treatment of dis- attendee surveys, reviews the con- ease also addressed the senses, the tent presented the preceding year, emotions, and the spirit – an early and asks itself what new areas of prototype for whole-person care – learning are need- with an emphasis on self-therapy ed, said Dustin through rest, relaxation, exercise, and Smith, MD, SFHM, the promotion of healthy lifestyles. hospitalist and associate profes- A different perspective on sor of medicine hospitals at Emory Uni- “People used to travel to Pergamon Study for the versity, Atlanta, for healing at the Asclepeion, next to and HM19 course the amphitheater, where plays and Dr. Messler director. music were presented, and to be out- FPHM exam “The confer- doors in the natural elements. Now ence’s schedule-at-a-glance of content we’re seeing hospitals being built can be overwhelming, so we have with healing gardens, and a new em- tried to use distinct educational phasis on how artwork and music at any given tracks to provide focus and clarity and environmental design can assist for conference attendees,” he said. in healing,” Dr. Messler said. “Every year there are a few areas His presentation will survey the moment. where questions often come up about advent of more recent hospitals in complex clinical situations where France in the 18th century, pioneer- established medical guidelines aren’t ing work done at Johns Hopkins much help.” Hospital in Baltimore and Bellevue For HM19 an educational mini- Hospital in New York, and the in- track, “Between the Guidelines,” was fluence on the modern hospital of developed to gather several of these pioneer Florence Nightingale areas of clinical complexity where (1820-1910). Her influence fundamen- Spark Edition 2 what’s available in established clini- tally changed the role of nursing in cal practice guidelines doesn’t offer hospitals, introducing professional clear answers, he said. These include training standards, he said. Answer questions online or off – controversies around antithrombot- The portico of the beautiful 15th from your couch, in an elevator, ic therapy in patients with major century Hospital of the Innocents bleeds, and a debate on controver- in Florence, Italy, the first organic between patients, or on an airplane. sial aspects of guidelines to direct creation of Filippo Brunelleschi (1377- inpatient care. 1446), marks the birth of Renaissance Another planned session, “The architecture in Florence, he added. History of Hospitals via Arts and The Hospital of Santa Maria Nuova, Stories,” fits nicely into this mini- founded in 1288, is the oldest hospital track, Dr. Smith noted. still active in Florence. “It’s a history lesson you can’t Part of the goal for this session Learn more: glean from medical guidelines, which is to take a break from clinically maybe points us toward what to focused presentations, and to think hospitalmedicine.org/spark incorporate and what not to repeat about the hospital from a different from across the history of hospitals,” perspective, Dr. Messler said. His he said. “That could help us better session will emphasize the power appreciate the work hospitalists are of stories and storytelling to inform doing today and into the future.” and inspire medical practice. Jordan Messler, MD, a hospitalist “We need to ask ourselves, ‘How with the Morton Plant Hospitalist can we analyze hospital history to group in Clearwater, Fla., will lead inform what we do today?’ ” the session. He says that modern physicians can learn a lot from both Reference the history of medicine and the evo- “Asclepeion.” Wikipedia. Accessed Jan. 28, lution of hospitals, starting with the 2019: https://en.wikipedia.org/wiki/Asclepeion. the-hospitalist.org | 13 | March 2019 HM19 PREVIEW

Well-rounded program Continued from page 1 at the conference to kick off plan- A well-rounded program ning for the following year’s confer- The HM19 educational program ence, then holds weekly conference will be well rounded, Dr. Smith said, calls for the next 4-5 months, Dr. offering clinical updates on topics Smith said. “These are all highly cre- such as sepsis, heart failure, and ative leaders in hospital medicine, new clinical practice guidelines. with voices to be heard and taken “You will see a big focus on wellness under consideration.” and how to avoid burnout, as well Committee members wear badges as other sessions on how to develop at the annual meeting to encourage and sustain a career in hospital med- attendees to offer them feedback icine,” he said. Another important and suggestions. “We have our ears HM19 theme will be the delivery of to the ground. We look at the session new models of population health and ratings from prior years, speaker rat- accountable care and their impact on ings, and all of the feedback we have both patients and hospital operations. received, and we take all of that into The 2019 agenda emphasizes oth- account to come up with new ideas ews er interactive formats, such as the for educational tracks,” Dr. Smith ge N “Great Debates,” where experts in

said. New for 2019 are “Between the MD e D the field are paired to debate clinical Guidelines” and “Clinical Mastery.” conundrums in hospital medicine. “We went around the table at our at HM19, not just for the workshop er we’re talking about wildfires or The number of Great Debates has meeting and asked everybody for tracks. Dr. Smith said all submis- mass shootings, it affects hospitals, grown from one on perioperative their ideas for new tracks, and then sions were peer reviewed by com- and we are among the frontline medicine at the 2017 annual confer- we voted in the most popular ones.” mittee members and scored with practitioners for whatever happens ence, to three in 2018, and now to One change for 2019 was to “com- objective ratings. in those hospitals. So we may need seven planned for 2019. “This format pletely open” the call for submission “For example, there was a lot of to be able to respond to large-scale is very popular. We’re also plan- of proposals – and for nominations interest in emergency and disaster emergencies,” he said. “But most of ning ‘Medical Jeopardy,’ with three of content to be covered and who preparedness for hospitalists in a us haven’t been trained for that.” brilliant master clinicians in a quiz should present it – for all sessions number of the submissions. Wheth- show format, and two ‘Stump the A love of teaching Professor’ sessions with expert diag- Dr. Smith’s preparation for being nosticians,” Dr. Smith said. the HM19 course director includes It’s important to make every ses- his work teaching medical students, sion at the conference interactive to residents, and physicians at Emory engage attendees in learning from, University where he also attended and talking to, experts in the field, he medical school. He chairs the Em- said. “But it’s also important for some ory division of hospital medicine’s of them to be more entertaining education council, directs hospital in approach as a way to encourage medicine grand rounds at Emory, learning. We know that this actually Don’t miss out on FREE and serves as associate program increases retention of information.” director for the J. Willis Hurst In- The annual conference course CME and MOC Credit ternal Medicine Residency Program director typically is selected several at Emory as well as a section chief years in advance, in order to plan for education in medical specialty for the time commitment that will at the Atlanta Veterans Affairs be required, and spends the year SHM members can earn over 130 AMA PRA Medical Center. Dr. Smith has also before this term as assistant course Category 1 creditsTM free through the codirected, since 2012, the annual director. “It is a big honor to serve as SHM Learning Portal. Southern Hospital Medicine region- course director. It’s fun and exciting al conference. to work with such a talented and Total CME and MOC credits earned in 2018: “I have long had an interest in diverse committee, but it’s also a lot medical education for medical stu- of work,” Dr. Smith acknowledged. 7,995 17,544 10,297 dents, trainees, and faculty and I “I reviewed all 450 session proposals e-learning course AMA PRA Category 1™ ABIM MOC wanted to do more of it – with a from this year’s open call for course completions credits issued points issued number of mentors encouraging content. The volume of emails is me along the way,” he said. “I have pretty outstanding, and I was ex- planned and coordinated teaching tremely busy with conference plan- Stay up-to-date with the SHM Learning Portal. sessions needed for maintenance of ning for a season.” shmlearningportal.org board certification, which is similar Dr. Smith has continued to pursue to what we will present at HM19. his full-time commitments at Emory, Based on that experience, I applied without getting dedicated time off to be on SHM’s annual conference for planning the SHM conference. The Society of Hospital Medicine is accredited by the Accreditation Council for Continuing Medical committee, starting in 2012 for the “But as a parent of three young chil- Education (ACCME) to provide continuing medical education for physicians. planning of Hospital Medicine 2013. I dren, I already feel busy all the time,” believe I have been preparing myself he said. “I put in a lot of late nights, all along to take on this role.” but I found a way to make it work.” March 2019 | 14 | The Hospitalist 24/7 Pediatric Medicine Solutions

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HOSP_15.indd 1 2/20/2019 10:01:06 AM INNOVATIONS | By Suzanne Bopp Creating innovative discharge plans ‘Long Stay Committee’ may help

ospitalists pay attention to length of solutions have included working stay as a measure of hospital efficiency with the patient and support per- and resource utilization; outliers on sons to find appropriate discharge that measure – “long stay patients” – levels of care throughout the Unit- Hwho present complex discharges are a barrier to ed States and other countries as length of stay reduction. To address this chal- well as guiding them through the lenge, one institution formed a multidisciplinary process to gain the necessary finan- Long Stay Committee and described the results in cial resources.” an abstract. hinkstock The authors conclude that the The Long Stay Committee is composed of med- td / t foundation of the committee’s suc- ical directors, the chief quality officer, directors cess in coming up with innovative in nursing, directors of case management/social discharge solutions is the broad work, hospitalists, risk management, finance, range of disciplines that attend this L avebreakmedia

ethics, psychiatry, and directors of rehabilitation. W committee and the atmosphere of The most complex patient discharges, identi- teamwork it creates. fied by case management and social work, are “The Long Stay Committee played an integral Reference brought to the Long Stay Committee. part in our institution partnering with the local Heacock A et al. Long Stay Committee finds innovative discharge “Lack of guardianship is one of the most en- county to form a guardian service board which plans for difficult discharges. Hospital Medicine 2018, Abstract countered barriers,” according to the authors. facilitates guardianship appointments. Other 312. Highlighting the value in Remembering the high-value care importance of caring Consumers learn about choices AI will change the practice of medicine

ospitalists can have a role to encourage high-value choices or s artificial intelligence (AI) allocate substantial time in the cur- in helping patients choose programs that educate consumers takes on more and more riculum to memorization and anal- Hand receive high-value care about how to use cost and quality Atasks in medical care that ysis – tasks that will become less from the vast array of health care information when seeking care,” he mimic human cognition, hospital- demanding as artificial intelligence choices they face. Helping them use said. ists and other physicians will need improves. The art of caring – com- quality and cost reports is one way There’s an opportunity for hospi- to adapt to a changing role. munication, empathy, shared deci- to do that, according to a recent talists to help consumers learn to Today AI can identify tuberculo- sion making, leadership, and team editorial by Jeffrey T. Kullgren, MD, use that information. “This strategy sis infections in chest radiographs building – is usually a minor part of MS, MPH. would approach consumerism as with almost complete accuracy, the medical school curriculum. We know that, if consumers a teachable health behavior and diagnose melanoma from images of Effective leadership and creativ- used public reporting of quality could be particularly helpful for skin lesions more accurately than ity are distant aspirations for arti- and costs to choose facilities that consumers with ongoing medical dermatologists can, and identify ficial intelligence but are growing generate the best health outcomes needs who face high cost sharing,” metastatic cells in images of lymph needs in a system of care that is for the resources utilized, it might he wrote. node tissue more accurately than ever more complex. improve the overall value of health “Some hospitalists may be in- pathologists can. The next 20 years At Dr. Johnston’s school, the Dell care spending. But most people volved in the implementation of are likely to see further acceleration Medical School at the University of choose health care services based programs to publicly report quality in the capabilities, according to a Texas at Austin, they have reduced on personal recommendations or and costs for their institutions,” recent article by S. Claiborne John- the duration of basic science in- the requirements of their insurance said Dr. Kullgren. “Others may treat ston, MD, PhD. struction to 12 months and empha- network. patients who have chosen hospitals “AI will change the practice of sized group problem solving, while Even if they wanted to use re- based on publicly reported informa- medicine. The art of medicine, deemphasizing memorization. This ports of quality or cost, the infor- tion, or patients who might be in- including all the humanistic com- has freed up additional time for in- mation in these reports is meant terested in using such information ponents, will only become more struction in the art of caring, lead- for providers and would likely be to choose sites of postdischarge important over time. As dean ership, and creativity. unhelpful for consumers. outpatient care. In each of these of a medical school, I’m training “Hospitalists should acknowledge Research suggests that different cases, it is important for hospi- students who will be practicing the value of caring,” Dr. Johnston presentation of the information talists to understand the oppor- in 2065,” Dr. Johnston said. “If I’m said. “They do it every day with could make a difference. “Simpler tunities and limits of such public not thinking about the future, I’m every patient. It is important today, presentations of information in reports so as to best help patients failing my students and the society and will be more important tomor- public reports may be more likely receive high-value care.” they will serve.” row.” to help consumers choose high- The contributions of AI will shift er-value providers and facilities,” Reference the emphasis for human care- Reference Dr. Kullgren said. Kullgren JT. Helping consumers make givers to the caring. Studies have Johnston SC. Anticipating and training the He concluded that consumers high value health care choices: The shown that the skills of caring are physician of the future: The importance of devil is in the details. Health Serv Res. caring in an age of artificial intelligence. may also need additional incen- 2018;53(4). http://www.hsr.org/hsr/abstract. associated with improved patient Acad Med. 2018;93(8):1105-6. doi: 10.1097/ tives, “such as financial incentives jsp?aid=53301961729. outcomes, but most medical schools ACM.0000000000002175. March 2019 | 16 | The Hospitalist INNOVATIONS | By Suzanne Bopp

Improving research dissemination es ycourse / ma G i etty

among hospitalists souther L G Social media a great platform Quick Byte: edical journals and ination metrics (i.e., page views societies are trying to and altmetrics scores), which figure out ways to use showed that each chat basically Trauma care social media to connect corresponded to a release of a new Innovating quickly Mwith hospitalists and others inter- issue. This could be informative ested in their subject matter, says to other journals as they look for Charlie Wray, DO, MS, lead author ways to increase their web traffic he U.S. military has com- of a paper proposing a way they or disseminate their work to their pletely transformed trauma can do that: implementing a jour- respective audiences.” care over the past 17 years,

hinkstock T nal-sponsored club on Twitter. Dr. Wray hopes the study alerts and that success offers lessons for “At the Journal of Hospital Med- hospitalists to the fact that there is civilian medicine. icine (JHM), we noticed that there a large and ever-growing communi- In the civilian world, it takes an 66/ t cyano was a large community of hospi- ty available within social media. average of 17 years for a new discov- talists on Twitter who were look- work that is being published in “Second, we know that careers ery to change medical practice, but ing for a community to engage in JHM.” in hospital medicine can be tough, the military has developed or signifi- hospital medicine topics,” Dr. Wray A study of #JHMChat showed regardless of whether you’re at a cantly expanded more than 27 major said. “We created #JHMChat to that social media is a great plat- or a large ac- innovations, such as redesigned bring the hospital medicine com- form for large organizations to ademic center. Knowing that there tourniquets and new transport pro- munity together on a regular basis reach out, connect, and create is a community with which you cedures, in about a decade. As a re- to talk about pertinent research, a community around, he added. can connect to is both comforting sult, the death rate from battlefield medical education philosophies, “We were very surprised by both and reassuring.” wounds has decreased by half. and value-based care interven- the Twitter metrics (i.e., number tions. Our ultimate goal was to of participants and overall im- Reference Reference increase engagement, networking, pressions), which showed very Wray C et al. The adoption of an online jour- Kellermann A et al. How the US military rein- nal club to improve research dissemination vented trauma care and what this means for US and communication among this large dissemination numbers, in and social media engagement among hospi- medicine. Health Aff. 2018 Jul 3. doi: 10.1377/ community, while highlighting the addition to the external dissem- talists. J Hosp Med. 2018 Nov;13(11):764-9. hblog20180628.431867.

Looking for a personalized #HowWeHospitalist approach to improve quality and patient safety at your hospital? March 7, 2019 is National Hospitalist Day. SHM’s Center for Quality Improvement

Join the Society of Hospital Medicine (SHM) in honoring Your partner in quality improvement. the hospital medicine care team. Learn how you and your institution can join the celebration and share your stories at hospitalmedicine.org/hospitalistday. hospitalmedicine.org/QI

the-hospitalist.org | 17 | March 2019 ANALYSIS Hospitalists and PTs: Building strong relationships Optimizing discharge disposition and longitudinal recovery

By Luann Tammany, PT, MBA aging patients in alternative pay- acute stay, not where they should ment models, such as accountable receive them. anctimonious, self-righteous, care organizations, bundled pay- discharge saboteurs. These ment programs, and Medicare Ad- Discharge disposition and are just a few descriptors vantage plans. Each model looks to longitudinal recovery I’ve heard hospitalists use to support a home recovery whenever PTs, as experts in function, have a Sdescribe my physical therapy (PT) possible and prevent readmissions. series of “special tests” at their dis- colleagues. posal beyond pain, range of motion, These charged comments come For hospitalists, working and strength assessments. These mostly after a hospitalist reads include Activity Measure for Post- therapy notes and encounters a con- collaboratively“ with PTs Acute Care (AM-PAC) or “6-Clicks” tradiction to their chosen discharge is crucial to improving the Mobility Score, Timed Up and Go, location for a patient. Six-Minute Walk Test, Tinetti, Berg value of care provided as I recently met with hospitalists Balance Scale, Modified Barthel Ms. Tammany is SVP of clinical from four different hospitals. They patients transition beyond Index, Five Times Chair Rise, and strategy & innovation for Remedy echoed the frustrations of their phy- the four walls of the Thirty-Second Chair Rise. These are Partners, Norwalk, Conn. sician colleagues across the country. all objective measures of function The PTs they work with write “the hospital. that can be used to inform discharge patient requires 24-hour supervision ” disposition and guide longitudinal situation, all of your test results and 3 hours of therapy a day,” or Case managers for Medicare recovery. including labs, x-rays and the func- “the patient is unsafe to go home Advantage programs routinely re- To elaborate on one tool, the tional tests performed by your PT, and needs continued therapy at an view PT notes to inform hospital 6-Clicks Mobility Score is a validated your potential for a full recovery is inpatient rehabilitation center.” The discharge disposition and postacute test that allows PTs to assess basic good. You have a moderate decline hospitalists in turn want to know authorization for skilled nursing fa- mobility.1,2 It rates six functional in function with a high likelihood “If I discharge the patient home am cility (SNF) admissions and days in tasks (hence 6 clicks) that include of returning home in the next 7-10 I liable if the patient falls or has SNF. Hospitalists, working with care turning over in bed, moving from days. I recommend you go to a SNF some other negative outcome?” The managers, can follow suit to succeed for high-intensity rehabilitation for frustration hospitalists experience in alternative payment models. They 7 days and that the SNF order PT is palpable and understandable as have the advantage of in-person PTs ... have a series and OT twice a day and walks with their attempts to support a home access to PT colleagues for elabora- “of ‘special tests’ at their nursing every evening.” recovery are often contradicted. tion and push-back as necessary. For This fully informed conversation hospitalists, working collaboratively disposal. can take place only if hospitalists Outside the four walls with PTs is crucial to improving the ” are provided clear, concise documen- The transition from fee-for-service value of care provided as patients lying to sitting, moving to/from bed tation, including results of objective to value-based care now calls upon transition beyond the four walls of to chair, transitioning from sitting functional testing, by their physical hospitalists to be innovators in man- the hospital. to standing from a chair, walking in therapy colleagues. a hospital room, and climbing three In conclusion, PTs working in the Working Together: The evolution of PT to five steps. These functional tasks acute setting need to use validated Hospitalists and PTs in acute care are scored based on the amount of tests to objectively assess function Prior to diagnosis-related groups assistance needed. The scores, in and educate their hospitalist col- (DRGs), PTs were profit centers for turn, have been shown to support leagues on the meaning of these Hospitalists hospitals – rehabilitation depart- discharge destination planning.1 In tests. Hospitalists in turn can incor- • Understand physical therapy ments were well staffed and easily addition to informing discharge des- porate these assessments into a dis- assessment of function to in- accommodated consults and re- tination decisions, hospitalists and cussion of discharge disposition and form discharge disposition and quests for mobility. the rest of the health care team can longitudinal recovery with patients. longitudinal recovery. With the advent of DRGs, physical use 6-Clicks to estimate prolonged In this way, hospitalists and physi- • Interpret all test results, in- therapy became a cost center, and hospital stays, readmissions, and cal therapists can work together to cluding PT, to inform discharge rehabilitation staffs were reduced. emergency department (ED) visits.3 achieve patient-centered, high-value disposition. PTs became overextended, were Of course, discharge disposition care during and following a hospi- Physical Therapists less available for consultations for is influenced by many factors in talization. • Identify what skilled services a mobilization, and patients suffered addition to functional status. Hospi- patient will need after hospital- the deleterious effects of immobility. talists are the obvious choice to lead References ization, not where they should With reduced staffing and a rush the health care team in interpreting 1. Jette DU et al. AM-PAC “6-Clicks” functional receive those services. to get patients out of the hospital, relevant data and test results, and assessment scores predict acute care hospi- • Support recommendations for acute PT practice morphed into to communicate these results to tal discharge destination. Phys Ther. 2014 Sep;94(9):1252-61. ongoing skilled services with evaluating functional status and de- patients and caregivers so together 2. Jette DU et al. Validity of the AM-PAC objective functional tests. termining discharge destination. they can decide the most appropri- “6-Clicks” inpatient daily activity and • Participate as part of the health Now, as members of an aligned ate discharge destination. basic mobility short forms. Phys Ther. 2014 care team, led by the physician, health care team, PTs need to facil- I envision a conversation be- Mar;94(3):379-91. in determination of discharge itate a safe home discharge when- tween a fully informed hospitalist 3. Menendez ME et al. Does “6-Clicks” Day 1 Postoperative Mobility Score predict discharge disposition. ever possible and determine what and a patient as follows: “Based disposition after total hip and knee arthroplas- skilled services a patient needs post- on your past history, your living ties?” J Arthroplasty. 2016 Sep;31(9):1916-20. March 2019 | 18 | The Hospitalist The Bridge from Critical Care to Recovery

v Kindred Hospitals have been at the leading edge of caring for pulmonary patients who require weaning from a ventilator. We specialize in pulmonary care that provides the extended recovery time needed by the patient.

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HOSP_19.indd 1 2/21/2019 9:25:10 AM CLINICAL In the Literature ITL: Clinician reviews of HM-centric research

By Bryan Huang, MD, FHM; Nhan Vuong, MD; Talya Bordin-Wosk, MD; Jonathan McIntyre, MD; and Constance Chace, MD, MPH Division of Hospital Medicine at the University of California, San Diego

IN THIS ISSUE & Medicaid Services (CMS) for hos- By Nhan Vuong, MD pital reimbursement, little is known Standardized communication 1. Additional physical therapy decreases length of stay about the effects of reimbursement 3 may prevent anticoagulant 2. Productivity-based salary structure not associated with value-based models on the culture of providing adverse drug events culture value-based care among individual CLINICAL QUESTION: What infor- 3. Standardized communication may prevent anticoagulant adverse hospitalists. The concern is that mation is needed on discharge to drug events productivity-based models increase reduce anticoagulant adverse drug 4. Early extubation to noninvasive ventilation did not decrease time to pressure on hospitalists to maximize events (ADEs)? liberation from ventilation volume and billing, as opposed to BACKGROUND: With increased use 5. Predicted risk of cardiac complications varies among risk calculators focusing on value. of anticoagulants, the amount of 6. Use of a CDSS increases safe outpatient management of low-risk PE STUDY DESIGN: Observational, related ADEs has patients cross-sectional, survey-based study. also increased. 7. Health care–associated infection rates going down SETTING: A total of 12 hospitals in ADEs may be 8. ARNIs effective for acute decompensated heart failure California, which represented uni- preventable 9. Exercise intervention reverses functional decline in elderly patients versity, community, and safety-net through improved during acute hospitalization settings. communication 10. Consider triple therapy for the management of COPD SYNOPSIS: Hospitalists were asked during transitions to complete the High-Value Care of care. The key Culture Survey (HVCCS), a validat- communication By Bryan Huang, MD, FHM therapy” across the heterogeneous ed tool that assesses value-based Dr. Vuong elements are not Additional physical therapy group of trials analyzed in this decision making. Components of standardized. 1 decreases length of stay meta-analysis. In all studies, the the survey assessed leadership and STUDY DESIGN: Delphi method. CLINICAL QUESTION: Does addi- experimental group received more health system messaging, data trans- SETTING: Consensus panel in New tional physical therapy reduce length physical therapy than the control parency and access, comfort with York state. of stay and improve outcomes? group, either by cost conversations, and blame-free SYNOPSIS: The New York State An- BACKGROUND: The optimal quan- increased fre- environments. Hospitalists were also ticoagulation Coalition (NYSACC) tity of physical therapy provided to quency or dura- asked to self-report their reimburse- tasked an expert multidisciplinary hospitalized patients is unknown. tion of sessions. ment structure: salary alone, salary panel of physicians, pharmacists, It has been hypothesized that the Nonetheless, plus productivity, or salary plus val- nurse practitioners, and physician costs of additional physical therapy hospitals may ue-based adjustments. assistants to develop a list of mini- might be outweighed by a decrease consider increas- A total of 255 hospitalists com- mum required data elements (RDEs) in length of stay. A prior meta-anal- ing physical ther- pleted the survey. The mean HVCCS for transitions of care using the Del- ysis done by the same authors was apy services as score was 50.2 on a 0-100 scale. Hos- phi method. inconclusive; subsequently, addi- Dr. Huang a cost-effective pitalists who reported reimburse- The following items are the 15 tional large trials were published, means of reduc- ment with salary plus productivity RDEs that require documentation: prompting the authors to repeat ing length of stay. adjustments had a lower mean (1) current anticoagulants; (2) indi- their meta-analysis. BOTTOM LINE: Additional physical HVCCS score (beta = –6.2; 95% con- cations; (3) new or previous user; STUDY DESIGN: Meta-analysis. therapy in acute and subacute care fidence interval, –9.9 to –2.5) when (4) if new, start date, (5) short-term SETTING: Literature review of En- settings results in a decreased length compared with hospitalists paid or long-term use; (6) if short term, glish-language studies conducted of stay and may be cost effective. with salary alone. An association intended duration; (7) last two worldwide. CITATION: Peiris CL et al. Addi- was not found between HVCCS doses given; (8) next dose due; (9) SYNOPSIS: A total of 24 randomized tional physical therapy services score and reimbursement with sal- latest renal function; (10) provision controlled trials with a total of 3,262 reduce length of stay and improve ary plus value-based adjustments of patient education materials; (11) participants was included in this me- health outcomes in people with when compared with salary alone, assessment of patient/caregiver ta-analysis. The primary finding was acute and subacute conditions: an though this finding may have been understanding; (12) future anticoag- that additional physical therapy was updated systematic review and me- limited by sample size. ulation provider; and if warfarin, (13) associated with a 3-day reduction in ta-analysis. Arch Phys Med Rehab. BOTTOM LINE: A hospitalist re- the target range, (14) at least 2-3 con- length of stay in subacute settings 2018;99(11):2299-312. imbursement model of salary plus secutive international normalized (95% confidence interval, –4.6 to –0.9) productivity was associated with ratio results, and (15) next INR level. and a 0.6-day reduction in acute care Productivity-based salary lower measures of value-based care BOTTOM LINE: Standardized com- settings (95% CI, –1.1 to 0.0). Further- 2 structure not associated with culture. munication during transitions of more, additional physical therapy was value-based culture CITATION: Gupta R et al. Associa- care regarding anticoagulation may associated with small improvements CLINICAL QUESTION: What hos- tion between hospitalist productiv- reduce anticoagulant ADEs. Objec- in self-care and activities of daily liv- pitalist reimbursement models are ity payments and high-value care tive evidence showing reduction of ing. One trial included an economic associated with value-based care culture. J Hosp Med. 2019;14(1):16-21. ADEs after implementation of the analysis that suggested additional culture? Dr. Huang is a physician adviser list is needed. physical therapy was cost effective. BACKGROUND: Although new and associate clinical professor in the CITATION: Triller D et al. Defining Of note, there was no standard payment models have been imple- division of hospital medicine at the minimum necessary anticoagu- definition of “additional physical mented by the Centers for Medicare University of California, San Diego. lation-related communication at March 2019 | 20 | The Hospitalist discharge: Consensus of the Care respiratory failure: The breathe Transitions Task Force of the New randomized clinical trial. JAMA. York State Anticoagulation Coali- 2018;320(18):1881-8. tion. Jt Comm J Qual Patient Saf. Dr. Vuong is an associate physician 2018;44(11):630-40. in the division of hospital medicine at the University of California, San Early extubation to Diego. 4 noninvasive ventilation did not decrease time to liberation By Talya Bordin-Wosk, MD from ventilation Predicted risk of cardiac CLINICAL QUESTION: In difficult 5 complications varies among to wean patients, does a weaning risk calculators protocol with noninvasive ventila- CLINICAL QUESTION: How fre- tion result in earlier liberation from quently is there concordance be- ventilation, compared with invasive tween three recommended risk weaning (continued invasive venti- calculators in categorizing a patient lation until successful spontaneous as low risk for major adverse cardiac breathing trial)? event (MACE)? BACKGROUND: Inclusion of nonin- BACKGROUND: A critical juncture vasive ventilation in weaning among in the American Heart Association/ chronic obstructive pulmonary American College of Cardiology 2014 disease (COPD) patients has been perioperative shown to reduce total duration of guidelines relies ventilation and invasive ventilator on clinicians cate- days with an associated reduction gorizing patients in morbidity and mortality. It is not undergoing non- well studied whether these results cardiac surgery apply to general ICU patients. as either low risk STUDY DESIGN: Randomized, allo- (less than 1%) cation-concealed, open-label, multi- or elevated risk center trial. Dr. Bordin-Wosk (greater than or SETTING: United Kingdom National equal to 1%) for Health Service ICUs. a MACE. The purpose of this study SYNOPSIS: Patients from 41 general is to determine whether there is adult ICUs met inclusion criteria variability between the three risk after they had been intubated for calculators endorsed by the ACC/ less than 48 hours and failed a AHA guidelines as prediction tools spontaneous breathing trial. Inten- to make this risk stratification. tion-to-treat analysis in 319 of 364 STUDY DESIGN: Retrospective ob- TRANSFORM YOUR patients (mean age, 63.1 years; 50.5% servational study. male) showed median time to liber- SETTING: National Surgical Quality ation of 4.3 days in the noninvasive Improvement Program database. PATIENT CARE. group versus 4.5 days in the invasive SYNOPSIS: The NSQIP database group (adjusted hazard ratio, 1.1; 95% was used to identify 10,000 patients confidence interval, 0.89-1.40). How- who had undergone noncardiac ever, secondary outcomes showed surgery. The risk of MACE for each reduction in median time of invasive patient was then calculated using ventilation (1 day vs. 4 days) and total the Revised Cardiac Risk Index, ventilator days (3 days vs. 4 days) in the American College of Surgeons the noninvasive group without a sig- National Surgical Quality Improve- nificant difference in adverse events. ment Program Surgical Risk Cal- Not all secondary outcomes were culator, and the National Surgical powered to detect treatment differ- Quality Improvement Program Myo- ences. Hospitalists should consider cardial Infarction or Cardiac Arrest noninvasive ventilation as an ad- calculator. Data were analyzed using junct in weaning, especially in COPD the intraclass correlation coefficient patients, to reduce ventilator-associ- and kappa analysis. Results demon- ated complications and ICU resourc- strated that 29% of the time the es when appropriate. three calculators disagreed on which TRANSFORM BOTTOM LINE: Protocolized early patients were classified as low risk. extubation to noninvasive ventila- This suggests that, when following tion was not associated with earlier the ACC/AHA perioperative guide- YOURSELF. liberation from all types of ventila- lines, a recommendation for further tion in the general ICU population. preoperative cardiac testing may de- CITATION: Perkins GD et al. Ef- pend on which risk prediction tool is fect of protocolized weaning with used to calculate the risk of MACE. Last chance to register! early extubation to noninvasive BOTTOM LINE: Nearly one-third shmannualconference.org ventilation vs invasive weaning on of the time, the three risk calcu- time to liberation from mechanical lators recommended in the ACC/ ventilation among patients with Continued on following page the-hospitalist.org | 21 | March 2019 Continued from previous page ate for home management of acute these domains. domized, double-blind, active-con- AHA 2014 perioperative guidelines PE decreased admission rates with- BOTTOM LINE: The overall prev- trolled trial. do not agree on which patients are out increasing adverse outcomes. alence of HAIs has decreased, but SETTING: A total of 129 centers in classified as low risk; this may affect CITATION: Vinson DR et al. Increas- further quality improvement work the United States. clinical decision making for some ing safe outpatient management is needed in order to expand this SYNOPSIS: Of 881 patients with patients. of emergency department patients reduction to health care–associated acute HFrEF, 440 were randomized to CITATION: Glance LG et al. Impact with pulmonary embolism: a con- pneumonia, C. difficile infection, and receive sacubitril/valsartan and 441 of the choice of risk model for iden- trolled pragmatic trial. Ann Int Med. mortality from HAIs. were randomized to receive enalapril. tifying low-risk patients using the 2018;169(12):855-65. CITATION: Magill SS et al. Changes The majority of patients were men; 2014 American College of Cardiology/ Dr. Bordin-Wosk is an assistant in prevalence of heath care–associ- mean age was 61 years. The primary American Heart Association periop- clinical professor in the division of ated infections in U.S. hospitals. N outcome was the mean reduction in erative guidelines. Anesthesiology. hospital medicine at the University of Engl J Med. 2018;379(18):1732-44. NT-proBNP concentration at weeks 2018;129(5):889-900. California, San Diego. 4 and 8 as compared with baseline. In ARNIs effective for acute the sacubitril/valsartan group, there Use of a CDSS increases safe By Jonathan McIntyre, MD 8 decompensated heart failure was a 46.7% reduction from baseline, 6 outpatient management of Health care–associated CLINICAL QUESTION: In patients and in the enalapril group, there low-risk PE patients 7 infection rates going down hospitalized for acute decompen- was a 25.3% reduction from baseline. CLINICAL QUESTION: Does the CLINICAL QUESTION: Have target- sated heart failure with reduced With regard to drug safety, there use of an electronic clinical decision ed quality improvement measures ejection fraction (HFrEF), is an an- was no difference between groups in support system (CDSS) increase the led to an improvement in the prev- giotensin receptor–neprilysin inhib- worsening renal function, symptom- number of low-risk patients with alence of health care–associated itor (ARNI) as effective as enalapril atic hypotension, or hyperkalemia. acute pulmonary embolism (PE) infections (HAIs)? in reducing levels of N-terminal of A limitation of this study is that discharged from the ED without in- BACKGROUND: HAIs are key the prohormone brain natriuretic 20% of patients in each group dis- creasing adverse events? drivers of morbidity and mortality peptide (NT-proBNP)? continued treatment by 8 weeks BACKGROUND: Despite multiple for hospitalized BACKGROUND: The PARA- secondary to an adverse event. Ad- guidelines that support outpatient patients. In 2011, DIGM-HF trial demonstrated that ditionally, a clinical measure such as management of acute PE in the the Centers for patients with chronic HFrEF treated cardiovascular mortality, all-cause appropriate patient population, Disease Control with an ARNI (sacubitril/valsartan) mortality, or rehospitalization for the rate of hospital admission for and Prevention had significantly reduced cardiovas- heart failure was not included in the patients eligible for outpatient man- (CDC) conducted cular mortality and hospitalizations primary outcome. agement remains high. One expla- a point-preva- when compared with enalapril. BOTTOM LINE: In patients with nation is that physicians may have lence survey that Patients with acute decompensated acute decompensated HFrEF, AR- difficulty identifying which patients revealed an HAI heart failure were excluded from NIs are more effective at reducing meet discharge criteria. Dr. McIntyre in 4% of hospital- this trial. The PIONEER-HF trial NT-proBNP levels than enalapril, STUDY DESIGN: Controlled prag- ized patients. The was designed to determine whether while maintaining a similar safety matic trial. most common infections included initiation of an ARNI in patients profile. Further investigation to SETTING: Kaiser Permanente North- pneumonia, gastrointestinal infec- with acute decompensated heart evaluate clinical outcomes needs to ern California (KPNC). tions, and surgical-site infections. failure is effective. be completed. SYNOPSIS: A total of 21 KPNC EDs Over time, efforts in patient safety STUDY DESIGN: Multicenter, ran- Continued on page 24 participated in this 16-month study and quality have expanded to re- of 1,703 patients; 11 EDs served as duce the rate of HAIs. This same Short Takes control sites and 10 as intervention survey was repeated in 2015 to as- sites. At month 9, ED physician sess for improvements. Pharmacist-led intervention reduced inappropriate medication study champions at intervention STUDY DESIGN: Point-prevalence prescriptions sites provided in-person training survey. An outpatient pharmacy-led intervention of notifying prescribing physi- on outpatient PE management, the SETTING: A collection of 199 Emerg- cians to discontinue inappropriate Beers Criteria medications resulted in validated PE severity index (PESI), ing Infection Program hospitals in a greater discontinuation of inappropriate medications for older adults and the electronic CDSS. The CDSS 10 states. at 6 months, compared with the control group (43% vs. 12% discontinu- was designed to use evidence-based SYNOPSIS: Of 12,299 patients ation). guidelines to assist physicians in surveyed, 3.2% (95% confidence CITATION: Martin P et al. Effect of a pharmacist-led educational inter- identifying patients eligible for interval, 2.9%-3.5%) were found to vention on inappropriate medication prescriptions in older adults: The outpatient care or short-term (less have at least one HAI. This was a D-PRESCRIBE randomized clinical trial. JAMA. 2018;320(18):1889-98. than 24-hour) observation in the ED. statistically significant reduction The CDSS was incorporated into the compared to the prevalence of 4% Omadacycline noninferior for community-acquired pneumonia electronic medical record navigator (95% CI, 3.7%-4.4%) found in the 2011 and acute bacterial soft tissue skin infections used by ED physicians and not only study. Approximately 75% of pa- Randomized, double-blind, double-dummy trials showed omadacycline calculated the PESI score, but also tients were on a medical ward, and is a noninferior alternative to moxifloxacin for the treatment of commu- provided the patient’s risk class and 15% of patients were in the ICU. nity-acquired pneumonia and to linezolid for acute bacterial soft-tissue 30-day all-cause mortality estimate. The age and sex of patients were skin infections. Adverse outcomes were defined as similar to those of patients in the CITATION: Nuzyra (omadacycline) [package insert]. Boston, MA: Paratek 5-day return visits for PE-related 2011 study. Pharmaceuticals. 2018. symptoms, recurrent VTE, major The reduction in HAIs was pri- hemorrhage, and all-cause 30-day marily driven by a reduction in Lack of evidence to support low-salt diet in adult heart failure mortality. Results demonstrated surgical-site infections and urinary patients an increase in home discharge at tract infections. There was no re- Systematic review of multiple databases demonstrated there is limited intervention sites (17.4% pre to 28% duction in the prevalence of health high-quality evidence to support current guidelines that recommend a post) without an increase in adverse care–associated pneumonia, Clos- low-salt diet to heart failure patients. outcomes. tridium difficile infection, or mortal- CITATION: Mahtani KR et al. Reduced salt intake for heart failure: A BOTTOM LINE: Use of an electronic ity. Consequently, this emphasizes systematic review. JAMA Int Med. 2018;178(12):1693-700. CDSS to identify patients appropri- the necessity of further work in March 2019 | 22 | The Hospitalist DOLLY ABRAHAM, MD, MBA, SFHM HOSPITAL MEDICINE

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HOSP_23.indd 1 2/19/2019 10:44:52 AM Continued from page 22 exercise regimens (focusing on re- acute hospitalization in elderly pa- associated with a significantly great- CITATION: Velazquez EJ et al. Angio- sistance, balance, and walking) or tients. er reduction in the rate of COPD tensin–neprilysin inhibition in acute standard hospital care (with phys- CITATION: Martinez-Velilla N et al. exacerbations, compared with dual decompensated heart failure. N Engl ical rehabilitation as appropriate). Effect of exercise intervention on therapy of LAMA and LABA (rate ra- J Med. 2018 Nov 11. doi: 10.1056/NEJ- Patients who received standard care functional decline in very elderly tio, 0.78; 95% con- Moa1812851. had a decrease in functional capac- adults during acute hospitalization. fidence interval, Dr. McIntyre is an associate ity at discharge when compared JAMA Intern Med. 2019;179(1):28-36. 0.70-0.88), inhaled physician in the division of hospital with their baseline function (mean corticosteroid and medicine at the University of change of –5.0 points on the Barthel Consider triple therapy LABA (rate ratio, California, San Diego. Index of Independence; 95% confi- 10for the management of 0.77; 95% CI, 0.66- dence interval, –6.8 to –3.2 points), COPD 0.91), or LAMA By Constance Chace, MD, MPH while those who received the exer- CLINICAL QUESTION: Does triple monotherapy Exercise intervention cise intervention had no functional therapy for chronic obstructive (rate ratio, 0.71; 9 reverses functional decline decline from baseline on discharge pulmonary disease (COPD) result in Dr. Chace 95% CI, 0.60-0.85). in elderly patients during acute (mean change of 1.9 points; 95% CI, lower rates of COPD exacerbations Triple therapy hospitalization 0.2-3.7 points). when compared with dual therapy was also associated with greater im- CLINICAL QUESTION: Can an indi- Patients who received the exer- or monotherapy? provement in FEV1. vidualized, multicomponent exercise cise intervention had significantly BACKGROUND: The Global Initia- There was a significantly higher program help reverse functional and higher scores on functional and tive for Obstructive Lung Disease incidence of pneumonia in patients cognitive decline in acutely hospital- cognitive assessments at discharge, (GOLD) recommends triple ther- using triple therapy, compared with ized, elderly patients? compared with patients who re- apy with inhaled corticosteroids, those using dual therapy (LAMA and

BACKGROUND: Acute hospital- ceived standard hospital care alone. long-acting beta2-adrenoceptor ag- LABA), and there also was a trend to- ization has been associated with Specifically, the study demonstrat- onists (LABA), and long-acting mus- ward increased pneumonia incidence functional and cognitive decline, ed a mean increase of 2.2 points carinic receptor antagonists (LAMA) with triple therapy, compared with particularly in elderly adults. This (95% CI, 1.7-2.6 points) on the Short for patients with severe COPD who LAMA monotherapy. Triple therapy decline is associated with increased Physical Performance Battery, 6.9 have frequent exacerbations despite was not shown to improve survival; morbidity and mortality. points (95% CI, 4.4-9.5 points) on the treatment with a LABA and LAMA. however, most trials lasted less than STUDY DESIGN: Single-center, sin- Barthel Index, and 1.8 points (95% Triple therapy has been shown to 6 months, which limits their analysis gle-blind, randomized clinical trial. CI, 1.3-2.3 points) on a cognitive as- improve forced expiratory volume of survival outcomes. SETTING: Acute care unit in a tertia- sessment, compared with those who in 1 second (FEV1), but its effect on BOTTOM LINE: In patients with ry public hospital in Navarra, Spain. received standard hospital care. preventing exacerbations has not advanced COPD, triple therapy is SYNOPSIS: 370 patients aged 75 BOTTOM LINE: An individualized, been well documented in previous associated with lower rates of COPD years or older who were hospitalized multicomponent exercise interven- meta-analyses. exacerbations and improved lung in an acute care unit received either tion can help reverse functional and STUDY DESIGN: Meta-analysis. function, compared with dual thera- individualized moderate intensity cognitive decline associated with SETTING: Studies published on py or monotherapy. PubMed, Embase, Cochrane Library CITATION: Zheng Y et al. Triple ther- website, Cochrane Central Register apy in the management of chronic of Controlled Trials (CENTRAL), and obstructive pulmonary disease: ClinicalTrials.gov databases. Systemic review and meta-analysis. SYNOPSIS: 21 randomized, con- BMJ. 2018;363:k4388. trolled trials of triple therapy in Dr. Chace is an associate stable cases of moderate to very physician in the division of hospital severe COPD were included in this medicine at the University of meta-analysis. Triple therapy was California, San Diego. Short Takes

Magnesium for rate control in rapid atrial fibrillation SHM Chapters Randomized, controlled trial demonstrated that intravenous magnesium sulfate in combination with atrioventricular (AV) nodal blocking agents World-class networking and resulted in better rate control for atrial fibrillation with rapid ventricular response than did placebo given in combination with AV nodal blocking education in your backyard. agents. CITATION: Bouida W et al. Low-dose magnesium sulfate versus high- dose in the early management of rapid atrial fibrillation: Randomized controlled double-blind study (LOMAGHI Study). Acad Emerg Med. 2019 Feb;26(2):183-91.

Low versus intermediate tidal volume strategy on ventilator-free days Connect with other hospital medicine professionals in ICU patients without ARDS in your area at in-person meetings or online in your Randomized, clinical trial of low tidal volume versus intermediate tidal chapter’s HMX community. volume strategies in invasively ventilated patients without accute respiratory distress syndrome (ARDS) demonstrated no difference in number of ventilator-free days, ICU length of stay, hospital length of Connect to your chapter • hospitalmedicine.org/chapters stay, incidence of ventilator-associated adverse events (ARDS, pneumo- nia, severe atelectasis, pneumothorax), or 28-day mortality. CITATION: Writing Group for the PReVENT Investigators, Simonis FD, Serpa Neto A. Effect of a low vs intermediate tidal volume strategy on ventilator-free days in patients without ARDS: A rand- omized clinical trial. JAMA. 2018;320(18):1872-80. March 2019 | 24 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Live. Hospitalists and Nocturnists Opportunities Available

Your work is your passion. But it’s not your whole life. Join a system that supports your need to balance work and home life. You can find great dining, art, entertainment, and culture in our cities, as well as peace and quiet in our rural areas. With opportunity for advancement and great schools and colleges nearby, it’s a great place to grow your career and your family. UPMC Pinnacle — a growing, multisite health system in south central Pennsylvania — Work . can meet your needs at one of our seven acute care hospitals

Join our Hospitalist Team ■ Traditional block and flexible schedules ■ Closed and open ICU environments available with options for procedures and dedicated code teams ■ Competitive salary — above MGMA median salary ■ Additional compensation for nocturnist and ICU coverage Balance. ■ Strong advanced practice provider support at all locations ■ Great administrative and clinical leadership support

Schedule a call with our recruiter today! Contact Tricia Deno Physician Recruiter [email protected] 717-231-8583

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UPMC Pinnacle is an Equal Opportunity Employer. EOE

Hospitalist & Nocturnist Opportunities in SW Virginia & NE Tennessee

Ballad Health, located in Southwest Virginia and Northeast Tennessee, is Full time positions with the following incentives: currently seeking Full Time, BE/BC, Day Shift Hospitalists and Nocturnist  Hospitalists to join its team. Hospital Employed (earning potential, exceeding $300K per year)  Day and Nocturnist Shifts (7 days on – 7 days off) Qualified candidates will work within Ballad Health Facilities and will need  Competitive Annual Salary an active Virginia and/or Tennessee license, depending on facility location.  Performance Bonus & Production Bonus  Excellent Benefits  Generous Sign On Bonus Facilities:  Relocation Assistance Ballad Health Southwest Virginia  Teaching and Faculty Opportunities with System Residency Programs Johnston Memorial Hospital, Russell County Medical Center, Smyth County  Critical Care Physician Coverage in most of the facilities CCU/PCUs Community Hospital, Norton Community Hospital, Mountain View Regional  Opportunity to Participate in Award-Winning Quality Improvement Projects Medical Center, Lonesome Pine Hospital

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the-hospitalist.org | 25 | March 2019 Make your next smart move. Visit shmcareercenter.org.

Hospitalist Opportunities with Penn State Health

Penn State Health is a multi-hospital health system serving patients and communities across central Pennsylvania. We are seeking IM/FM trained physicians interested in joining the Penn State Health family in various settings within our system. Enriching every life we What We’re Offering: touch…including yours • Community Setting Hospitalist opportunities (Lancaster and Berks County positions) • We’ll foster your passion for patient care and cultivate a Gundersen Health System in La Crosse, Wis. is seeking a(n) collaborative environment rich with diversity nocturnist/internist to join our established hospitalist • Commitment to patient safety in a team approach model team. Gundersen is an award-winning, physician-led, • Experienced hospitalist colleagues and collaborative integrated health system, employing over 500 physicians. leadership Practice highlights: • Salary commensurate with qualifications • 182 shifts per year (primary schedule 7 on 7 off) consisting • Relocation Assistance of purely nights. Shift lengths are approximately 8 hours in What We’re Seeking: duration • Internal Medicine or Family Medicine trained • Collaborative, cohesive hospitalist team established in 2002 • Ability to acquire license in the State of Pennsylvania with high retention rate and growth • Must be able to obtain valid federal and state narcotics • 30-member internal medicine hospitalist team comprised certificates of 20 physicians and 10 associate staff • Current American Heart Association BLS and ACLS • Primary responsibility is adult inpatient care; telemedicine certification required responsibilities to our critical access hospitals on a • BE/BC in Family Medicine or Internal Medicine (position dependent) rotational basis • Manageable daily census No J1 visa waiver sponsorships available • Excellent support and collegiality with subspecialty services What the Area Offers: • Competitive compensation and benefits package, Penn State Health is located in Central Pennsylvania. Our local neighborhoods boast a reasonable cost of living whether you prefer a including loan forgiveness more suburban setting or thriving city rich in theater, arts, and culture. Our surrounding communities are rich in history and offer an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major For information contact Kalah Haug, Medical Staff cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC. Recruitment, at [email protected]. or (608) 775-1005. For more information please contact: Heather J. Peffley, PHR FASPR, Penn State Health Physician Recruiter [email protected]

Equal Opportunity Employer Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled. Gundersen Lutheran Medical Center, Inc. Gundersen Clinic, Ltd. | 21972-11 0219

Hospitalist Opportunity Based in Greenwood, S.C., Self Medical Group is DAYTIME & NIGHTTIME a multi-practice, multi-specialty group, seeking a HOSPITALISTS BE/BC Hospitalist and Nocturnist for an expanding practice. To advertise in • Work a 7on/7off, 12-hour schedule with NO call. Long Island, NY. NYU Winthrop Hospital, a 591-bed, or the university-affiliated medical center and an American College • Excellent work-life balance with comfortable The Hospitalist of Surgeons (ACS) Level 1 based in Western patient volumes Nassau County, NY is seeking BC/BE internists for academic • Competitive salary package and benefits, Journal of Hospital Medicine Hospitalist positions. including student loan assistance • EPIC EMR Ideal candidates will have exemplary clinical skills, a strong Contact: interest in teaching house staff and a long term commitment • Intensivist Provides majority ICU care to inpatient medicine. Interest in research and administration • Self Regional is an 11-time Gallop Great Heather Gonroski a plus. Salaried position with incentive, competitive benefits Workplace award recipient 973.290.8259 package including paid CME, malpractice insurance and vacation. About Greenwood, S.C.: [email protected] Just an hour from Columbia and Greenville, DRIVEN TO BE Greenwood, or as it is called the “Emerald City,” or Interested candidates, please offers a temperate climate, year-round golf and email CV and cover letter to: the best. recreation and lakeside living at pristine Lake Linda Wilson [email protected] Greenwood. It is also home to the S.C. Festival of or fax to: (516) 663-8964 973.290.8243 Flowers, a celebration of flora that features larger- Ph: (516) 663-8963 [email protected] Attn: Vice Chairman, Dept of Medicine-Hospital Operations than-life topiaries during the month of June. An EOE m/f/d/v Contact: Twyla Camp NYU Winthrop Hospital is located in the heart of Nassau Physician Recruiter County in suburban Long Island, 30 miles from NYC and 864-725-7029 just minutes from LI’s beautiful beaches. [email protected] March 2019 | 26 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

ERIC TAKAHASHI, DO HOSPITAL MEDICINE

JOIN OUR HOSPITALIST TEAM:

■ Spotsylvania Regional Medical Center Fredericksburg, VA ■ Ft. Walton Beach Medical Center Ft. Walton Beach, FL ■ Turkey Creek Medical Center Knoxville, TN ■ Raulerson Hospital Okeechobee, FL ■ Gulf Coast Medical Center Panama City, FL ■ North Knoxville Medical Center Powell, TN

Opportunities in Georgia, Florida, Tennessee, Kentucky and Virginia

877.265.6869 [email protected]

the-hospitalist.org | 27 | March 2019 Make your next smart move. Visit shmcareercenter.org.

Med/Peds Hospitalist Hospitalist Opportunities in Eastern PA Opportuniti es Available Join the Healthcare Team at – Starting Bonus and Loan Repayment – Berkshire Health Systems

Berkshire Health Systems is currently seeking BC/BE Med/Peds physicians to join our comprehensive Hospitalist Department We have day positions at our Miners Campus in beautiful Schuylkill County and at our newest • Day and Nocturnist positions hospital in Monroe County set in the Pocono Mountains. Both campuses offer you an opportunity • Previous Med/Peds Hospitalist experience is preferred to make a difference in a Rural Health Community yet live in your choice of family friendly, thriving • Leadership opportunities available Located in Western Massachusetts Berkshire Medical Center is the suburban areas. In addition, you’ll have access to our network’s state of the art technology and region’s leading provider of comprehensive health care services Network Specialty Support Resources. We also have opportunities at our Quakertown campus, • Comprehensive care for all newborns and pediatric inpatients including: where a replacement hospital will open in 2019. o Level Ib nursery o 7 bed pediatrics unit o Care for pediatric patients admitted to the hospital We offer: • Comprehensive adult medicine service including: • o 302-bed community with residency programs Starting bonus and up to $100,000 in loan repayment o Geographic rounding model • 7 on/7 off schedules o A closed ICU/CCU • Additional stipend for nights o A full spectrum of Specialties to support the team • Attractive base compensation with incentive o A major teaching affi liate of the University of Massachusetts Medical • School and University of New England College of Osteopathic Medicine Excellent benefits, including malpractice, moving expenses, CME • 7 on/7 off 12 hour shift schedule • Moonlighting Opportunities within the Network We understand the importance of balancing work with a healthy personal lifestyle • Located just 2½ hours from Boston and New York City SLUHN is a non-profit network comprised of physicians and 10 hospitals, providing care in eastern • Small town New England charm • Excellent public and private schools Pennsylvania and western NJ. We employ more than 800 physician and 200 advanced practitioners. • World renowned music, art, theater, and museums St. Luke’s currently has more than 220 physicians enrolled in internship, residency and fellowship • Year round recreational activities from skiing to kayaking, this is an ideal programs and is a regional campus for the Temple/St. Luke’s School of Medicine. Visit www.slhn.org. family location. Berkshire Health Systems offers a competitive Our campuses offer easy access to major cities like NYC and Philadelphia. Cost of living is low coupled salary and benefi ts package, including relocation. with minimal congestion; choose among a variety of charming urban, semi-urban and rural communities Interested candidates are invited to contact: your family will enjoy calling home. For more information visit www.discoverlehighvalley.com Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. Please email your CV to Drea Rosko at [email protected] Applications accepted online at www.berkshirehealthsystems.org

Physician-Led Medicine in Montana ICU Hospitalist/Nocturnist CHA Everett Hospital Internal Medicine/Family Medicine Cambridge Health Alliance (CHA) is a well-respected, nationally recognized and award-winning public healthcare system, which receives Hospitalist recognition for clinical and academic innovations. Our system is comprised of three hospital campuses in Cambridge, Somerville and Everett with additional outpatient clinic locations throughout Boston’s Metro North Region. CHA is an academic affiliate of both Harvard Medical School (HMS) and Tufts University School of Medicine. We are a clinical affiliate of Beth Israel Deaconess Medical Center. Generous loan repayment CHA is recruiting for an ICU Hospitalist/Nocturnist to cover Everett Hospital. Seeking a BE/BC Hospitalist • Position requires PM shifts (7p-7a) plus weekend day shifts and a Nocturnist to join our • Work collaboratively with CHA’s intensivist MDs to round on inpatients group in Montana’s premier, within the CHA Everett Hospital ICU state-of-the-art medical • Cross coverage of med/surg inpatient unit included as part of clinical center, which serves as the responsibility (10% of total FTE) region’s tertiary referral • Applicants should be comfortable with procedures including central center. Our seasoned team lines, vent management, intubation, etc. values work-life balance • Internal training and maintenance program exists to assist in and collegiality. certification of these skills competencies To advertise in • • Extremely flexible Academic appointment is available commensurate with medical school scheduling or the criteria The Hospitalist • Shifts reduced for Applicants should be trained and Board Certified in Internal Medicine or Nocturnist Billings Clinic is nationally Journal of Hospital Medicine Family Medicine and possess excellent clinical and communication skills • Generous salary with recognized for clinical plus a demonstrated commitment to CHA’s multicultural, underserved excellence and is a proud patient population. yearly bonus • Signing bonus member of the Mayo Clinic At CHA, we have a supportive and collegial clinical environment with strong • No procedures required Care Network. Located in leadership, . CHA has a fully integrated electronic medical Billings, Montana – this CONTACT: record system (Epic) throughout our inpatient units and outpatient clinics. • J-1 waivers accepted friendly college community is We offer a competitive, guaranteed base salary and comprehensive benefits • “Top 10 Fittest Cities in a great place to raise a family Heather Gonroski package. America 2017” – Fitbit near the majestic Rocky 973.290.8259 Please visit www.CHAproviders.org to learn more and apply through our • “America’s Mountains. secure candidate portal. CVs may be sent directly to Lauren Anastasia, Manager, [email protected] Best Town Exciting CHA Provider Recruitment via email at [email protected]. CHA’s of 2016” outdoor or Department of Provider Recruitment may be reached by phone at (617) 665- Contact: Rochelle Woods Linda Wilson 3555 or by fax at (617) 665-3553. recreation 1-888-554-5922 close to We are an equal opportunity employer and all qualified applicants will receive 973.290.8243 physicianrecruiter@ home. 300 consideration for employment without regard to race, color, religion, sex, sexual billingsclinic.org [email protected] orientation, gender identity, national origin, disability status, protected veteran days of status, or any other characteristic protected by law. billingsclinic.com sunshine! #1 in Montana March 2019 | 28 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Chief of Hospitalist Medicine Opportunity in Northeast Pennsylvania

Job description: n Oversees the development of the annual budget and key operating indicators for the Guthrie Clinic, a non-profit, physician-led, integrated health care delivery system is Department and monitors the Department’s performance in relation to these annual seeking candidates for Chief, Section of Hospitalist Medicine. The Chief will oversee 24 targets. Hospitalists and 9 Advanced Practice Providers, located in 4 regional hospitals. The Chief n Works collaboratively with the Program Director for the Internal Medicine Residency has responsibility for quality, leadership, scheduling and overall program strategy. Program, the Fellowship Directors and the Director of Medical Education to ensure that the quality of the residency and fellowship(s). Position details and requirements: n M.D. or D.O.; BC in Internal Medicine. Advanced degree (MBA, MHA, MMM) desirable. n Ensures the Section functions in an integrated system of care, improving performance, n Five or more years of successfully leading a Hospitalist program. growing depth of clinical programs, and enhancing quality outcomes. n Strong commitment to the patient care and future academic missions of n Serves as mentor, guide and support for Hospitalists system wide. Guthrie Clinic. n Leads recruitment/retention of physicians and APPs to actively grow the Section. n Possession of, or eligibility for, a medical license in Pennsylvania. n Position is 50% Administrative and 50% clinical. Clinical Guthrie, founded in 1910, provides comprehensive team-based care to patients from an • Participates in quality and system improvement within group and across hospital. 11-county service area. Guthrie Clinic is comprised of four hospitals, 500 physicians and • Participates in all group clinical decisions with the goal of high quality care. advanced practice providers in a regional office network made up of 45 sub-specialty • Participates in group performance reviews with regard to quality of care, satisfaction, and sites in 21 communities. In addition, we offer a wide range of services and efficiency metrics. and programs including home health and home care services, GME and a research • Coordinates schedule with group to maintain 24/7 coverage at all hospitals within the institute. Guthrie was the first system to implement EPIC EMR, in 2002, with the go-live integrated health system. of Epic CPOE (Certified Physician Order Entry). • Ensures coverage of shifts. Guthrie's (main) Sayre campus is situated in a beautiful valley in north-central PA, Administrative located just a few miles from the NY border. Guthrie’s service area stretches from • Participates in strategic plan for hospital medicine group, including marketing, growth/ Corning and Ithaca, NY to Wellsboro, PA (home of PA Grand Canyon) down to recruiting, service, and quality. Tunkhannock, PA and is less than 30 minutes from the Finger Lakes region. • Establish annual goals for quality, efficiency growth and satisfaction. • Responsible for developing, updating and maintaining clinical standards and care For more information about this leadership opportunity, please contact Krisi VanTassel paths. at [email protected] or (570) 887-5203, www.ichoseguthrie.org. • Participates in utilization review and peer review activities as they relate to the Hospitalist program.

ichoseguthrie.org

the-hospitalist.org | 29 | March 2019 Make your next smart move. Visit shmcareercenter.org.

HOSPITALISTS/ NOCTURNISTS NEEDED IN SOUTHEAST LOUISIANA Joy. Make it part of your career.

Vituity provides the support and resources OchsnerOchsner Health System is seeking physicians to join our you need to focus on the joy of healing. hospitalist team. BC/BE Internal Medicine and Family Medicine We currently have opportunities for hospitalists and intensivists at hospitals and skilled nursing practices across physicians are welcomed to apply. Highlights of our opportunities are: the country. Some with sign-on bonuses up to $100,000!  Hospital Medicine was established at Ochsner in 1992. We have a stable 50+ member group  7 on 7 off block schedule with flexibility  Dedicated nocturnists cover nights  Base plus up to 45K in incentives  Average census of 14-18 patients  E-ICU intensivist support with open ICUs at the community hospitals  EPIC medical record system with remote access capabilities  Dedicated RN and Social Work Clinical Care Coordinators  Community based academic appointment  The only Louisiana Hospital recognized by US News and World Report Distinguished Hospital for Clinical Excellence award in 4 medical specialties  Co-hosts of the annual Southern Hospital Medicine Conference  We are a medical school in partnership with the University of Queensland providing clinical training to third and fourth year students  Leadership support focused on professional development, quality improvement, and

 Opportunities for leadership development, research, resident and medical student teaching  Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels with an interest in geriatrics  Paid malpractice coverage and a favorable malpractice environment in Louisiana  Generous compensation and benefits package Ochsner Health System is Louisiana’s largest non-profit, academic, healthcare system. Driven by a mission to Serve, Heal, Lead, Educate and Innovate, coordinated clinical and California hospital patient care is provided across the region by Ochsner’s 29 owned, managed and • Fresno • Redding • San Jose affiliated hospitals and more than 80 health centers and urgent care centers. Ochsner is • Modesto • San Diego • San Mateo orld Report as a “Best Hospital” across four specialty categories caring for patients from all 50 states and more than 80 Illinois Missouri Oregon countries worldwide each year. Ochsner employs more than 18,000 employees and over • Belleville • St. Louis • Eugene 1,100 physicians in over 90 medical specialties and subspecialties, and conducts more than • Greenville 600 clinical research studies. For more information, please visit ochsner.org and follow us on Twitter and Facebook. Interested in travel? Interested physicians should email their CV to [email protected] Check out our Reserves Program. or call 800-488-2240 for more information. Future leader? Reference # SHM2017. Apply for our Administrative Fellowship. Sorry, no opportunities for J1 applications. We proudly sponsor visa candidates!

Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, disability For more information, please contact us at status, protected veteran status, or any other characteristic protected by law [email protected].

To learn more, visit www.the-hospitalist.org and click “Advertise” or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

March 2019 | 30 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

HOSPITALIST OPPORTUNITIES IN ARIZONA & COLORADO At the end of the day, this is where you want to be. Join the Banner Health Team in Phoenix, Tucson or the Northern Colorado Front Range – where you’ll have the time to connect with your patients, your practice, your family and the great outdoors! We offer dedication to work/life balance unmatched in our industry. Meaning you get to spend more time doing what you love. That’s HEALTH CARE made easier, LIFE made better!

• Physician-led • System focus on patient and provider well-being • Non-profit status means continuing reinvestment • Autonomy in your practice • Access to research and academics • Robust compensation & total rewards

Email CV to: [email protected] and learn more at bannerdocs.com

VISIT US AT BOOTH 517 DURING 2019 SHM!

Banner Health is an EEO/AA - M/W/D/V Employer.

Hospitalist Regional Medical Director Opportunities in Eastern PA Hospitalist Opportunity Available – Starting Bonus and Loan Repayment – Join the Healthcare Team at Berkshire Health Systems! St. Luke’s University Health Network (SLUHN) is interviewing for Hospitalist Regional Medical Director Candidates for our growing Berkshire Health Systems is currently seeking 10-. This is an opportunity to lead a dynamic BC/BE Internal Medicine physicians to join our group of physicians at several campuses, engage them as a comprehensive Hospitalist Department team and work to assure consistent high quality. All campuses • Day, Evening and Nocturnist positions have a closed ICU, strong advanced practitioner assistance and • Previous Hospitalist experience is preferred Find your all specialty back up, in addition to an opportunity for upward Located in Western Massachusetts Berkshire mobility within the Network. Medical Center is the region’s leading provider of next job today! SLUHN is a non-profit network comprised of physicians and 10 comprehensive health care services hospitals, providing care in eastern Pennsylvania and western • 302-bed community teaching hospital with NJ. We employ more than 800 physician and 200 advanced residency programs visit SHMCAREERCENTER.ORG practitioners. St. Luke’s currently has more than 220 physicians • A major teaching affi liate of the University of enrolled in internship, residency and fellowship programs and is Massachusetts Medical School and UNECOM a regional campus for the Temple/St. Luke’s School of Medicine. • Geographic rounding model Visit www.slhn.org • A closed ICU/CCU • A full spectrum of Specialties to support the team We offer: • 7 on/7 off 10 hour shift schedule • Starting bonus and up to $100,000 in loan repayment We understand the importance of balancing work with a • 7 on/7 off schedules healthy personal lifestyle • Additional stipend for nights • Located just 2½ hours from Boston and New York City • Attractive base compensation with incentive • Small town New England charm • Excellent benefits, including malpractice, • Excellent public and private schools moving expenses, CME • World renowned music, art, theater, and museums • Moonlighting Opportunities within the Network • Year round recreational activities from skiing to kayaking, this is an ideal family location. Our campuses offer easy access to major cities like NYC and Berkshire Health Systems offers a competitive salary and benefits Philadelphia. Cost of living is low coupled with minimal congestion; package, including relocation. choose among a variety of charming urban, semi-urban and rural communities your family will enjoy calling home. For more information Interested candidates are invited to contact: visit www.discoverlehighvalley.com Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems Please email your CV to Drea Rosko at 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. [email protected] Applications accepted online at www.berkshirehealthsystems.org the-hospitalist.org | 31 | March 2019 Make your next smart move. Visit shmcareercenter.org.

We provide the support and flexibility needed to balance your career and life outside of medicine.

Join our team teamhealth.com/join or call 855.879.3153

UNIVERSITY OF MICHIGAN DIVISION OF HOSPITAL MEDICINE

The University of Michigan, Division of Hospital Medicine seeks board certified/board eligible internists to join our growing and dynamic division. Hospitalist duties include teaching of medical residents and students, direct patient care in our non-resident and short-stay units and involvement in quality improvement and patient safety initiatives. Novel clinical platforms that feature specialty concentrations (hematology/oncology service, renal transplant service and bone marrow transplant teams) as well as full-time nocturnist positions are also available. Our medical short stay unit provides care for both observation and inpatient status patients and incorporates advanced practice providers as part of the medical team.

The ideal candidate will have trained at, or have clinical experience at a major US academic medical center. Sponsorship of H1B and green cards is considered on a case-by-case basis for outstanding individuals. Research opportunities and hospitalist investigator positions are also available for qualified candidates.

The University of Michigan is an equal opportunity/affirmative action employer and encourages applications from women and minorities. HOW TO APPLY Interested parties may apply online at www.medicine.umich.edu/hospital-medicine or email cover letter and CV to Vineet Chopra, MD, MSc, Chief, Division of Hospital Medicine at [email protected].

WWW.MEDICINE.UMICH.EDU/HOSPITAL-MEDICINE

March 2019 | 32 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

The Ohio State Wexner Medical Center Join a Leader in Hospital Medicine

As one of the nation’s largest academic hospitalist programs, we lead a variety of teaching and non-teaching inpatient and consultative services. OSUWMC Division of Hospital Medicine is dedicated to the health and well-being of our patients, team members, and our

Our Faculty Enjoy: OSUWMC community. Our mission is to improve the lives of our patients and faculty by

Manageable clinical workload with flexible providing personalized, patient-centered, evidence-based medical care of the highest scheduling options quality. We are currently seeking exceptional physicians to join our highly regarded team. Competitive salary & bonus including a rich Preferred candidates are BC/BE in Internal Medicine or Internal Medicine-Pediatrics, have benefit package Faculty appointment commensurate with work experience or residency training at an academic medical center, and possess excellent experience inpatient, teamwork, and clinical skills. Research & teaching opportunities as well as ongoing education and development programs Natasha Durham, DASPR Occurrence-based malpractice and relocation [email protected] allowance [email protected] NOW INTERVIEWING COMPETITIVE APPLICANTS http://go.osu.edu/hospitalmedicine

We are an Equal Opportunity/Affirmative Action Employer, Qualified women, minorities, Vietnam-era and disabled Veterans, and individuals with disabilities are encouraged to apply. This is not a J-1 opportunity.

Seeking Changemakers We Enable National Hospitalists to Transform Healthcare

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HNI Healthcare partners with inspired clinical providers to relentlessly pursue meaningful results. Enabled by VitalsMD™ technology, propelled by our vision, we will forge a bold path for a new model of healthcare - and your daring transformation.

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Open Regions Include: California, Florida, Idaho, Louisiana, Ohio, and Texas

Send CV: [email protected]

the-hospitalist.org | 33 | March 2019 Make your next smart move. Visit shmcareercenter.org.

Sweet Hospitalist Opportunity with Penn State Health

Penn State Health is a multi-hospital health system serving patients across central Pennsylvania seeking Chicago—Vibrant City, exceptional physicians to join our Penn State Health family to provide patient care as a Hospitalist. Family Friendly Suburbs What we’re offering: • Faculty positions as well as non-teaching hospitalist positions within our multi-hospital system as well as our outpatient IMMEDIATE OPENINGS-Advocate Medical practices; • Network with experienced hospitalist colleagues and Group (AMG), a part of Advocate Health collaborative leadership; • Ability to develop quality improvement projects in transition Care, is actively recruiting HOSPITALISTS for of care and other scholarly pursuits of interest; growing teams across metro Chicago. • Commitment to patient safety in a team approach model; • Potential for growth into leadership roles; • Flexible 7 on7 off scheduling • Competitive salary, comprehensive benefit package, relocation, and so much more! • Manageable daily census What we’re seeking: • Established, stable program with • Collaborative individual to work with diverse population and staff; 120+ providers • Medical degree - MD, DO, or foreign equivalent; • Completion of an accredited Internal Medicine or • First-rate specialist support Family Medicine program; • Comprehensive benefits, relocation & • BC/BE in Internal or Family Medicine; • Must have or be able to acquire a license to practice in the Commonwealth of Pennsylvania; CME allowance • No J1 visa waiver sponsorships available. What the area offers: Advocate Medical Group is part of Located in a safe family-friendly setting in central Pennsylvania, our local neighborhoods boast a reasonable cost of living whether Advocate Aurora Health – the 10th largest you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Our communities are rich in history and offers an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major not-for-profit health system in the nation. cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC. For more information please contact: Heather Peffley, Physician Recruiter at: [email protected] Submit CV & cover letter to [email protected] Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled. Tomorrow starts today.

H ospitalist and n octurnist p osition a vailable Great Opportunity for a Location, Location, Location Hospitalist in the Southwest San Juan Regional Medical Center in Farmington, NM is recruiting for a hospitalist. This opportunity offers a great place to live, a caring community and hospital environment with a team committed to offering personalized, compassionate care. • 100% Hospitalist work • Wide variety of critical care • $275,000 base salary + productivity and quality bonus • Excellent Benefits

Concord :30 Boston Interested candidates should contact Come join our well established hospitalist team of dedicated Emerson Hospital provides advanced medical services Terri Smith | [email protected] hospitalist at Emerson Hospital located in historic Concord, to more than 300,000 people in over 25 towns. We are a 888.282.6591 or 505.609.6011 Massachusetts. Enjoy living in the suburbs with convenient 179 bed hospital with more than 300 primary care doctors sanjuanregional.com | sjrmcdocs.com access to metropolitan areas such as Boston, New York and and specialists. Our core mission has always been to make Providence as well as the mountains, lakes and coastal areas. high-quality health care accessible to those that live and work Opportunities available for hospitalist and nocturnists; full in our community. While we provide most of the services time, part time, per diem and moonlighting positions, just that patients will ever need, the hospitals strong clinical 25 minutes from Boston. A great opportunity to join a well collaborations with Boston’s academic medical centers established program. ensures our patients have access to world-class resources Classified Advertising for more advanced care. For more information please FIND THE PERFECT FIT! • Manageable daily census contact: Diane M Forte, Director of Physician Recruitment • Flexible scheduling to ensure work life balance For more information on placing your classified adver- and Relations 978-287-3002, [email protected] • Dedicated nocturnist program tisement in the next available issue, contact: • Intensivists coverage of critical care unit Not a J-1 of H1B opportunity Heather Gonroski • 973.290.8259 • Competitive compensation and bonus structure [email protected] • Comprehensive benefit package including CME allowance or • Access to top specialty care Linda Wilson • 973.290.8243 emersonHospital.org [email protected]

March 2019 | 34 | The Hospitalist Practice Management The past and future of hospital medicine Challenges faced, and overcome

By John Nelson, MD, MHM clude in the hospitalist-specific test portunities, but when I think about or board exam that I had speculated the past and future of our field and hile I hope I’ll still be might be in our future. I took his our Society, I’m reminded of many doing much the same tone and body language to suggest past accomplishments and a promis- work for many more his main intent was to convey that ing future. years, I’m clearly at a I was crazy to think that such a test When Win Whitcomb, MD, MHM, Wstage of life that most of my career might ever be worthwhile. and I founded SHM, I had the idea is behind me. So I guess it’s natural A pregnant silence followed his that among its most important roles that I think about the past a little question, after which I gave a tenta- would be serving as a forum for more than I used to. And one of the tive response that I worried made exchange of ideas among hospital- things that makes me smile is how me sound dumb. So like George ists and providing robust practice I’m like George Costanza in The in “Seinfeld,” I continued to think management resources for hospi- Comeback episode of “Seinfeld.” about this, and days later came up talist groups. Through the efforts In 1997 I had just delivered a pre- with what I’m sure would have been of so many people, including Angela sentation about what the future a terrific comeback that would have Musial, the first SHM staff person, might hold for hospitalists to the gotten a robust laugh from the au- and so many other staff and mem- roughly 110 attendees at the first dience without being demeaning to bers, we now have dozens of active in-person meeting of SHM (then the questioner. For the last 22 years special interest groups, informative known as the National Association I’ve been waiting for someone to ask publications, an active online dis- Dr. Nelson is cofounder and past of Inpatient Physicians). During the me the same question so I can final- cussion forum, and blogs. And our president of SHM, and principal in Q&A that followed, someone asked ly deliver my winner of a response. annual conference has grown a lot Nelson Flores Hospital Medicine me what clinical content I would in- There have been other missed op- from that first meeting of 110 peo- Consultants in La Quinta, Calif. He ple; HM19 will bring together nearly is codirector for SHM’s practice 5,000 of us to educate, inspire, and management courses. support one another. Collectively, there are a lot of ideas being ex- changed through SHM. When SHM was brand new I had When SHM was brand hope that it would grow. But I never new“ I had hope that it guessed that hospital medicine would become the fastest-growing field in would grow. But I never the history of U.S. health care. guessed that hospital I also never guessed that the term “nocturnist” would become a medicine would become standard part of our field’s lexicon. I the fastest-growing field in used it solely as a reliable way to get the history of U.S. health a laugh and find it really funny and delightful that it caught on. care. And OB hospitalists? Neurohos- ” pitalists? I never saw these and the only solution might be to reduce pa- many other variations coming at all. tient loads, but that isn’t a sustain- But I see it as validating an idea first able solution in the long term. I’m adopted by medicine and pediatrics. convinced we need to offload much But dermatology hospitalists? Yep, of the work we do today that isn’t that’s a thing too. The hospitalist purely clinical, so that a typical hos- model has been adopted, in at least a pitalist in the future can see more few places, by nearly every specialty patients each day without working in medicine. harder or longer. And it is terrific that March 7, 2019, I imagine a future in which the is the first National Hospitalist Day. typical hospitalist goes home after SHM made this happen too. seeing 20 or more patients in a day I also think about the future of and isn’t completely exhausted and our field and see some pretty big stressed, but sees it as a good day challenges, though our past success at work. I’m not sure exactly how as a field makes me confident we’ll we’ll get there, but it will probably navigate them effectively. include things like no longer having The burden of administrative, reg- to devote any time or attention to ulatory, and EHR-related tasks just whether the patient is inpatient or keeps growing for hospitalists. This observation status, or whether they often means it is difficult or impos- have had a qualifying 3-midnight An image of the earliest incarnation of The Hospitalist: The National Association sible to see as many patients in a stay so Medicare will cover a skilled of Inpatient Physicians (NAIP), mentioned by Dr. Nelson in his column, was the day as might have been reasonable nursing facility. I’m excited to see precursor to SHM. in the past. In the near term, the how this will evolve. the-hospitalist.org | 35 | March 2019 Me, at my best.

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