All Entries Tagged With: "richard rohr"
I can’t get no sa-tis-fac-tion
Patient satisfaction is going to emerge soon as an issue for hospitalists. Communication with doctors is one of the components of the federally-mandated HCAHPS surveys for hospitals, and payment may eventually be linked to that measure.
Administrators are very sensitive to complaints, and more of them seem to be generated by hospitalist service patients than other services. The reasons are not hard to understand; the hospitalist usually has no prior relationship with the patient, may not know the preferred communication style for that patient, and is under pressure to reduce length of stay and conserve hospital resources.
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Hospitalist with a capital “H”
By Richard Rohr, MD, MMM, FACP, FHM
I worry a bit about the self confidence of recently trained hospitalists. When I started my first program, it was in a small hospital that had a good range of consultants, but most of them were located primarily at larger hospitals and were not always available for immediate consultation. Under those circumstances, we stretched ourselves a bit and handled a wide variety of problems, including critical care, on our own.
I consider myself an Internist with a capital I, because I am willing to manage all types of adult medical problems, with judicious use of consultants and liberal use of references such as UpToDate. Some physicians enjoy practicing in rural areas because it gives them the opportunity to use skills and perform procedures that are reserved for subspecialists in urban areas. I spent a year in a rural hospital with hardly any consultants but still managed to care for a lot of problems on my own.
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9/11: A remembrance
By Richard Rohr, MD, MMM, FACP, FHM
I had not planned to write about this, but seeing the 9/11 memorials this morning brought back some memories.
At 8 a.m. on September 11, 2001 we convened a meeting of the Department of Medicine at Milford Hospital in Milford, CT. The major topic of discussion was whether or not hospitalists should have full membership and privileges in the department. I had been hired several years earlier as a “daytime house physician” (Bob Wachter had not yet told us what a hospitalist was), and we had recently recruited full-time physicians to replace moonlighting cardiology fellows from Yale who had provided night coverage for many years. We were ready to launch a full-service hospitalist program, but there were still many members of the private medical staff who saw this as a way for the hospital to diminish the physicians’ control. It was a more contentious meeting than usual, and I recall that the privileges were approved by a single vote.
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Blogging: It’s a two-way street
By Richard Rohr, MD, MMM, FACP, FHM
Writing a blog can be an exercise in self-indulgence. Any notion that comes to mind can seem like the wisdom of the ages when set into type on a Web page. What keeps the blogger grounded in reality is the response from the readers.
My intention of my last posting, “A Contrarian view of hospital medicine,” was to bring out a point of view not often discussed in public forums but to represent some of the lingering doubts about the legitimacy of hospital medicine. I express my appreciation to the individuals who have posted their reactions to my piece. I especially appreciate the contribution of Jon Lovins for stating what is positive and progressive about hospital medicine. I happen to know Jon from my days in Conn.; he and his sister Rachel are both progressive forces in hospital medicine.
A contrarian view of hospital medicine
By Richard Rohr, MD, MMM, FACP, FHM
I wrote several months ago about the necessity of hospital medicine. While I still think that hospitalists occupy a vital niche in the healthcare system, let’s consider a perspective that generally has not been expressed.
One of the reasons why hospitalists have become necessary is that hospitals have become unmanageable places for doctors to practice. When I finished training in 1985 and joined the medical staffs at several small hospitals, I was greeted by a vice president in each of those institutions. Each VP asked the same questions: “What can we do for you?” and “Can we buy any equipment for you?” Utilization review was rudimentary in those days; formulary controls were few and far between; and there were not many computers in nursing stations. Doctors did pretty much want they wanted to do when they wanted to do it, and hospitals catered to their whims.
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Health reform and the hospitalist
By Richard Rohr, MD, MMM, FACP, FHM
Some sort of health reform is likely to be enacted by Congress before the year is out, and we can be sure that it will change hospital medicine in some manner, but details are still hazy.
We will see some expansion of coverage to the currently uninsured, which would help hospital medicine groups, but I am not sure that universal coverage will be achieved this year. Don’t look for a single payer system–this country is too pluralistic to accept that. Private insurers will continue to play an important role, and you’ll probably keep all or most of your present billing numbers.
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Hospital medicine as a career
By Richard Rohr, MD, MMM, FACP, FHM
I just got back from the SHM meeting in Chicago, and what a great meeting it was. The specific content is very well covered elsewhere on this Web site, so I’m going to reflect on my journey through the years with this organization. I became a hospitalist in 1996, without knowing what a hospitalist was, because Bob Wachter hadn’t explained it yet.
All I knew was that a small hospital near my home was looking for a doctor to coordinate care during the days so primary physicians could concentrate on their office practices. I was at a crossroads in my career, having worked in two staff-model HMOs (both now defunct) and coming off a foray into long-term care that had not developed as I had hoped. The hospital didn’t offer much money, but I took the job because of one thing my prospective boss said—“You could change the practice of medicine in this town.”
The paradox of specialty hospitals
By Richard Rohr, MD, MMM, FACP
Recent conflicts between specialty and general hospitals is an issue that gets to the heart of the schizophrenic manner in which America finances hospital care, but it is not something that many hospitalists have thought about. It does have a bearing on hospitalist practice; bear with me while I explain the issue.
Many years ago, hospitals charged for services based on the actual number of days patients spent in the hospital, plus any drugs and supplies used. This system allowed hospitals to grow and prosper, but it provided no stimulus for reducing costs.
In 1983, the federal government introduced its Prospective Payment System for Medicare hospital benefits. The idea was to create a global budget for each hospital based on the types of patients treated and local operating costs. The concept was to create an ideal payment for each medical condition, expressed as a Diagnosis Related Group (DRG), and reward more efficient hospitals, while penalizing the less efficient. Payment became separated from actual costs.
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The necessary evil of hospital medicine
I was talking to a physician last week about a hospitalist program when he referred to it as “a necessary evil.” I have been thinking about the ways in which hospital medicine is both necessary and evil.
The necessary part comes about from the rapidly disappearing traditional primary care practice in the United States. Few new physicians are choosing to practice primary care, whether it is internal medicine, pediatrics, or family practice. Those who remain in the field are squeezed financially and must concentrate on office practice to make an adequate income. The financial strain is the reason that is most often cited as the necessity of hospital medicine.
The rapture of the seven-on/seven-off schedule
I have been thinking a lot about hospitalist schedules, both for my own program and for others that I am consulted on. I have tried for many years to set up eight-hour shifts, only to be told that “we need our days off”.
The seven-on/seven-off schedule holds a strange fascination for hospitalists, especially those who have recently completed residency. When you as the resident have worked 80 hours a week for three years, now doing so every other week, while collecting a salary close to $200,000, sounds like an incredible deal.
The fact is that a seven-on/seven-off schedule with 12-hour shifts comes out to 2,184 hours a year, which is very close that the maximum that people can generally sustain without burnout. During the “on” weeks, there is essentially no time for activities other than work and sleep. All of your personal activities must be conducted during the “off” weeks. The perception of vast amounts of free time is just an illusion.
There is also the matter of recovery after a fatiguing week that sometimes involves nighttime work. I am reminded of a recent TV clip. After Joaquin Phoenix appeared on the David Letterman Late Show and gave no evidence of participation, Letterman said to Phoenix, “It’s too bad that you couldn’t make it tonight.”
Who is a qualified hospitalist?
The recent formation of the American Board of Hospital Medicine (ABHM) creates a new wrinkle in the ongoing quest by hospitalists to define themselves and get recognition for their unique skills. Many hospitalists have been seeking a special board certification unique to their specialty. The new ABHM would seem to fit the bill, except for a few things.
One problem is that ABHM is not part of the American Board of Medical Specialties (ABMS), which is the umbrella organization for the major boards such as American Board of Internal Medicine (ABIM) and American Board of Surgery (ABS). ABHM belongs to an organization called the American Board of Physician Specialties (ABPS), which hosts a number of boards that parallel the major boards. [more]
