Welcome to our second annual Top Hospitalists issue. Our requests for nominations—sent out last spring and summer—asked for hospitalists who are making notable contributions to the field, whether through clinical skills, research, innovation, teamwork, community involvement, improved work flow, patient safety, leadership, mentorship or quality improvement. And our readers delivered: The breadth and depth of the hospitalists nominated attest to the great work being done in U.S. hospital medicine.
ACP Hospitalist's editorial board members reviewed the nominations and selected 10 Top Hospitalists, who are profiled on the following pages. They are teachers and innovators, mentors and researchers, leaders and hospital medicine pioneers. Some have distinguished themselves by helping younger physicians get ahead, while others are making great strides in patient safety and care transitions. All have contributed enormously to the field of hospital medicine. We're excited to recognize the work of these extraordinary individuals. We hope you enjoy reading about them—and we look forward to receiving your nominations for next year's honorees.
(ACP Hospitalist's Top Hospitalist feature is not considered part of the ACP National Awards Program.)
Collaborative philosophy breaks down communication barriers
Alpesh N. Amin, FACP
Medical school: Northwestern University, Chicago
Residency: University of California at Irvine
Current titles: Professor and chair, department of medicine, and executive director, hospitalist program, UC Irvine
Since launching one of the first multidisciplinary hospitalist programs in the country, Alpesh N. Amin, FACP, has discovered that a group can be much more than the sum of its parts. Under his direction, the nine-specialty group at the University of California at Irvine Medical Center has pioneered a collaborative approach that has raised the profile of hospitalists and fostered improvements throughout the hospital system.
“We have experts within our group in nine different areas and that elevates everyone to develop more of a skill set in areas where they may not have had formal training,” said Dr. Amin. “Our physicians can walk next door and talk to someone who specializes in neurology or infectious diseases—breaking down those barriers has been very positive.”
Closer collaboration among specialties means faster consultations and encourages a systems-based approach to managing patient care, said Dr. Amin. “When you want to implement something like a medication reconciliation program or DVT prevention, you can do it across the system through the hospitalist program.”
UC Irvine's hospitalist program was one of the first of its kind when launched by Dr. Amin in 1998. Dr. Amin has since become the first hospitalist in the nation to chair a department of medicine at a university medical center. The program has received numerous accolades over the years, including being named one of the top 50 U.S. hospitals by U.S. News & World Report for nine years running. In 2008, Dr. Amin, who also holds an MBA in health care, was awarded ACP's Laureate Award for excellence in medical care, education and research.
Dr. Amin has initiated many new protocols at UC Irvine aimed at improving quality and patient safety. For example, he spearheaded the development of new venous thromboembolism prevention guidelines for admission order sets. “Before physicians finalize their order set, they have to answer questions around prevention,” he explained, “and that's helped us get VTE prevention rates up significantly.”
The improvements are borne out by statistics: In 2008, UC Irvine had the lowest 30-day mortality index and length-of-stay index among California teaching hospitals, according to data compiled by the University HealthSystem Consortium. The hospital had the third lowest 30-day and 14-day readmission rates.
While he's still involved in patient care, Dr. Amin spends significant time managing the hospitalist team. He initiated required monthly team meetings and meets with individual specialties on a regular basis. He's also developed incentive models that encourage teamwork and collaboration.
“I treat the hospital program almost like a hospital department, with each specialty area like a division or section,” said Dr. Amin. “We are all tied together financially as well as clinically.”
Because of their involvement in both quality and resource management, hospitalists are ideally situated to lead health system reform, Dr. Amin said. “Having hospital-based physicians as part of the overall health care delivery team that works with other areas in the system is very important. We help ensure good transitions of patients and communication among physicians.”
Star researcher on cutting edge of QI before it was a buzzword
Vineet Arora, FACP
Medical school: Washington University Medical School, St. Louis, Mo.
Residency: University of Chicago
Current titles: Assistant professor of medicine; associate program director, internal medicine residency; and assistant dean, Pritzker School of Medicine, University of Chicago
A decade ago, Vineet Arora, FACP, was something of an outlier in the medical research community when she began to zero in on hospital systems and quality improvement. Today, she's recognized as an international expert on physician handoffs and communication, and it's clear that her work was ahead of the curve.
“During residency, the focus is on patient care but I was also very interested in system issues in the hospital,” said Dr. Arora. “I was intrigued by why the system doesn't work and how to make it better, and I also became interested in how policies are made locally and nationally.”
Because of these interests, Dr. Arora took an atypical path out of residency, spending two years pursuing a master's degree in public policy and an additional year serving as chief resident instead of going directly into teaching. “I wanted to see how I could apply public policy to the care of patients and improving resident education,” she said.
Dr. Arora's star rose among academic researchers after she published numerous articles, including one in Annals of Internal Medicine (2006;144:792-8) and another in the Journal of the American Medical Association (2008;300:1146-53), that were heavily cited in the Institute of Medicine's 2008 report on resident duty hours. Her research accomplishments prompted the Society of Hospital Medicine to ask her to chair its task force on hospitalist handoffs, which resulted in recommendations that were published in the September 2009 Journal of Hospital Medicine, with Dr. Arora as lead author. She has also received a grant from the Agency for Healthcare Research and Quality to evaluate handoffs in residents and hospitalists.
“It's been an interesting area to work in because so little is known about it,” said Dr. Arora of her work in handoffs and communication. “It's something that interns, residents and hospitalists do a lot of but that no one really has been taught how to do correctly.”
Dr. Arora has developed a research niche in improving quality of care of hospitalized older patients, including treatment of pressure ulcers and sleep problems. Although it's still early in her career, Dr. Arora has gained accolades for her mentorship of younger physicians and students.
“The accomplishments of Dr. Arora's mentees are innumerable and range from regional and national abstract presentations to first-author publications in well-respected peer-reviewed journals,” noted Jeanne M. Farnan, MD, a colleague at the University of Chicago who nominated Dr. Arora as a Top Hospitalist.
In her new role as assistant dean for scholarship and discovery at the Pritzker School of Medicine, Dr. Arora is working on implementing a formal curriculum for medical students to pursue projects in diverse areas such as research, quality and safety, community health, global health and medical education.
Dr. Arora views her roles as mentor and educator as natural extensions of her research interests. “I see myself continuing to study and teach about handoffs and seeing if we can achieve better outcomes,” she said. “The nice thing about studying handoffs is that [this area] needs to be improved and better taught—a lot of our work now is focusing on how to teach it.”
Working on payer and clinical sides offers best of both worlds
Thomas J. Biuso, ACP Member
Medical school: New York Medical College, New York City
Residency: Albany Medical Center, Albany, N.Y.
Current titles: Medical director, United Healthcare; clinical assistant professor, University of Arizona College of Medicine; and part-time hospitalist with AIM Physicians, Tucson, Ariz.
Physicians and payers often don't see eye to eye on patient care and cost issues, but what if a practicing physician also worked for a payer? Thomas J. Biuso, ACP Member, has found that living in both worlds is a good way to discover common ground.
“I don't think it's done very often but I wish all hospitalists could do it,” said Dr. Biuso, who oversees United Healthcare's operations in eight acute care hospitals in Pima County, Ariz. “Being a medical director makes me a better hospitalist and, likewise, working as a hospitalist makes me a better medical director. The roles allow me to find common ground.”
Recent attention to industry performance measurements highlighted how one role informs the other, said Dr. Biuso, who developed hospitalist programs in Tucson and Phoenix for Apogee Physicians before joining United Healthcare. For example, being clinically active allows him to assess which performance measurements are in sync with current practice and which are less useful or based on outdated evidence.
As UnitedHealthcare medical director, Dr. Biuso meets with each of the six hospital medical groups in Tucson at least quarterly to present United Healthcare data on readmission rates, length of stay for different conditions and other key indicators. The meetings allow hospitalists to share best practices, measure internal productivity and see how they measure up compared to other area hospitalist groups. Dr. Biuso also meets with the administrators at the larger hospitals in Tucson to discuss utilization and quality issues as well as ways for greater collaboration between the hospital and United.
Because Dr. Biuso follows United patients through the system, he provides data on post-discharge outcomes for those who transition to long-term acute care, inpatient rehabilitation and skilled nursing facilities. Before transfer, he confers with physicians about the best post-acute care options based on patients' clinical condition and ongoing need for medical resources.
“We [all] want the same thing: the highest functional status for the patient,” he said. “If I'm thinking one thing and the hospitalist or specialist another, I call the physician to discuss the individual case and come to an agreeable decision in order to, hopefully, prevent a readmission and allow the patient to reach his or her highest level of functional well-being.”
Educating younger physicians is another priority for Dr. Biuso. One of the lessons he tries to impart to residents is the importance of the bedside exam and the most cost-effective use of medical resources.
“In morning report, it is not infrequent to hear the intern or resident requesting the results of an imaging study prior to asking for the details of the physical examination,” said Dr. Biuso. “I explain to the housestaff that technology is complementary to a good history and physical examination. The latter allows the physician to develop a more targeted differential diagnosis and, therefore, evaluation.”
His philosophy on the use of expensive medical resources dovetails nicely with his role as medical director. Appropriate use of imaging and other technology provides potential cost savings for the health care system.
“Dr. Biuso stresses bedside physical examination skills and how to integrate those findings with lab tests and imaging to create a differential diagnosis,” said Ana Maria Lopez, FACP, a colleague who nominated Dr. Biuso as a Top Hospitalist. At the same time, “he works to provide a dialogue regarding the best and most up-to-date practices for different clinical conditions.”
For Dr. Biuso, practicing clinical medicine while pursuing his interests in population health management at United Healthcare gives him the best of both worlds.
“I have this privileged position [at United] that provides me a 30,000-foot view of the health care infrastructure in Pima County,” he said. “But then I also get to actually become one of the working doctors interacting with our physician network and caring for sick patients.”
Individual mentoring lays foundation for team's success
Brian J. Harte, FACP
Medical school: University of Pennsylvania, Philadelphia
Residency: University of California, San Francisco
Current titles: Chairman, Cleveland Clinic Department of Hospital Medicine, and medical director, Cleveland Clinic Enterprise Business Intelligence/ Medical Operations, Cleveland
The reaction of Brian J. Harte, FACP, to being named a Top Hospitalist says a lot about his approach to leadership. The recognition was affirmation, he said, that his entire team is succeeding.
“That people would recognize me, hopefully, is a reflection that I recognize them,” said Dr. Harte. “Being a good leader is about taking care of your people, identifying their talents and giving them the tools and advocacy they need to succeed.”
Dr. Harte joined Cleveland Clinic five years ago, and the department of hospital medicine was created two years ago. In that time, Dr. Harte revamped aspects of the organization. He advocated for the resources and recognition necessary for a new department's growth—boosting staff morale—and his team added services such as nurse practitioners, embedded consultants to surgical services, and nocturnists that have improved workflow and helped reduce length of stay.
Dr. Harte, who oversees a group of about 40 hospitalists, still cares for patients on the wards, but the bulk of his time is devoted to management and administrative responsibilities. He gets the most satisfaction out of seeing individual physicians perform at their highest level because they want to be part of a high-performing team.
“Everyone is on the same page in terms of understanding what constitutes success for the clinic, that it's about efficient, reliable, high-quality patient care,” Dr. Harte observed. “Everyone understands which way the ship is headed and where we're trying to get to.”
Dr. Harte has increased team satisfaction in a variety of ways, from making sure staff physicians have their own offices to backing quality improvement projects and advocating for support services. Due to Dr. Harte's efforts, “the department of hospital medicine now has a strategic position in the institution,” said Moises Auron-Gomez, FACP, a colleague who nominated Dr. Harte as a Top Hospitalist. “We are the ones that triage all the medical admissions to the institution which again consolidates the stronger image toward the department from the whole Cleveland Clinic staff.”
As a deputy editor of the Journal of Hospital Medicine, Dr. Harte has helped young staff submit research articles and participate as peer reviewers, said Dr. Auron-Gomez. He has also helped strategically position the department within the internal medicine residency program by having hospitalists become crucial contributors to the residents' morning report and lead teaching services.
Other innovations pioneered by Dr. Harte's team include supporting morning multidisciplinary rounds with social workers, case managers and nursing staff; empowering a triage officer or “quarterback” to ensure patients are assigned to appropriate services; and working with information technology to install inpatient electronic health records and computerized physician order entry systems.
His approach to leadership is modeled largely on his own personal mentors, Dr. Harte said. His program director at a previous position, in a private hospitalist practice in California, was “instrumental in helping me understand leadership and advocating for young people,” he said. “She was someone that people looked up to in terms of her emotional intelligence, maturity and the way she advocated for us. On the public face, she was always there to support us, and any performance issues that we did have were always vetted internally.”
At Cleveland Clinic, he has frequent meetings with another leader in the organization, where “we talk about specific challenges that I have and life in general,” Dr. Harte explained. “I ask him about his thoughts and he gives me reading assignments. People who work directly for him would throw themselves in front of a bus for him … that's the sort of person I've always looked up to.”
Dr. Harte has tried to incorporate some of the qualities he admires in his mentors into his own leadership style. He meets with team members individually and tries to identify and nurture their career interests early on.
That nurturing starts from the minute new staff physicians walk in the door, according to Dr. Auron-Gomez. “He welcomes all the new staff with the question ‘What can I do to help you achieve your goals?’”
Commitment to compassion inspires younger physicians
Jose L. Lezama, FACP
Medical school: University of Florida, Gainesville, Fla.
Residency: University of South Florida, Tampa, Fla.
Current titles: Chief of medicine, James Haley Veterans Hospital, and associate program director, University of South Florida College of Medicine, Tampa, Fla.
Medical students and residents who stop by the office of Jose L. Lezama, FACP, are often surprised to note a Buffalo Bills football team sticker displayed on his wall—a curious choice for a diehard fan of the Tampa Bay Buccaneers. Those who ask soon discover that the sticker has personal significance for Dr. Lezama, who leaps at the opportunity to tell one of his favorite patient care stories.
“The story is special and nice for them to hear,” said Dr. Lezama, explaining the bond he formed with a patient he treated for congestive heart failure, who gave him the sticker as a token of their friendship before he died in 2005. “It's so important for my students and residents to see that interaction because there's a fear that hospitalists can't form the kinds of bonds with patients that [are] possible in primary care.”
Dr. Lezama is known for his ability to motivate and inspire younger physicians, evidenced by his numerous teaching awards. His board review series was instrumental in boosting resident pass rates to 97% to 99% for the past seven years, prompting internal medicine residents to vote him Teacher of the Year at the USF College of Medicine for five years running.
“He is an outstanding physician with more dedication to his patients than I have seen in my career from anyone else,” said Alexander I. Reiss, ACP Member, a colleague who nominated Dr. Lezama as a Top Hospitalist. “His contributions as an expert at our medical morning report have established him as the ‘go-to guy’ for difficult cases and advice for younger faculty.”
One of Dr. Lezama's first priorities when he became chief of medicine almost four years ago was to formalize the hospital medicine section to put hospitalists on a par with other specialties. During his brief tenure, he has also spearheaded several other groundbreaking initiatives, including establishing an electrophysiology program and introducing a new protocol for community-acquired pneumonia (CAP).
Establishing the electrophysiology program meant that physicians no longer had to send patients elsewhere for specialized cardiac care. In just one year, the hospital went from one half-time to three full-time electrophysiologists on staff and the service is now flourishing. Still, getting the project off the ground required a culture shift.
The process took “a lot of meetings and communication with nursing staff and other technician staff to buy into the philosophy that this is new and we can do this and it will just take some time for us to become efficient,” said Dr. Lezama, who has already moved on to adding state-of-the-art technology and building a dedicated catheterization lab.
The CAP initiative called for a systemic solution but also drew upon his mentorship and leadership skills, said Dr. Lezama. On the systems side, he created a handout for physicians and placed order sets in the electronic medical record so that antibiotic choices appear on screen immediately as a doctor writes a prescription. It took another set of skills to convince residents to change their mindset about CAP.
“There is literature showing that the quicker patients get antibiotics when they present with pneumonia, the better they do,” Dr. Lezama explained. “I wanted to change the culture of thinking there was no rush to get [CAP] patients antibiotics. I started giving them feedback and that helped them see how well they were doing and the processes where they could have done better.”
Of all his achievements, it's the recognition from students that means most to Dr. Lezama. Before accepting the chief of medicine position, he made sure that he wouldn't have to give up teaching and mentoring students and residents, which accounts for about one-quarter of his time.
“Mentoring is invaluable,” he said. “Students naturally look up to those in high positions for mentorship and we have to be ready to deliver it.”
Taking an entrepreneurial approach to improving care
Diane S. Pine, ACP Member
Medical school: Mount Sinai School of Medicine, New York City
Residency: University of Rochester, Rochester, N.Y.
Current titles: Medical director, hospitalist service, Orange Regional Medical Center, Middletown, N.Y., and managing partner, Hudson Valley Hospital Physicians
Diane S. Pine, ACP Member, doesn't just provide services, she solves problems. So when the folks at Orange Regional Medical Center said they needed to improve their pre-surgical testing protocol, Dr. Pine set out to determine what an ideal program would look like and build it from the ground up.
“It's been a huge undertaking,” said Dr. Pine, who is in the process of launching the initiative in the departments of orthopedics and neurospine surgery and plans to roll it out to all departments over the next six months. “We formed six subcommittees to reject, accept or change the existing protocols based on the literature, and we revamped nursing's protocols so that physicians and nurses were looking at the same information and everyone was launched in the same direction.”
The new protocol requires surgeons to stratify patients according to whether they need pre-surgical care by nurses, anesthesiologists, internists or all of the above. It also implements strict guidelines for leading the patient through surgery and post-operative management.
“Most surgical complications are medical complications, such as pneumonias, myocardial infarctions or deep vein thrombosis,” Dr. Pine explained. “So you want to minimize the risk as best you can and it should be based on the literature. A lot of doctors clear their patients but they're not adhering to the evidence, so we created a very locked-down program where patients are cleared and managed only by doctors trained in perioperative medicine.”
The successful initiative, among other factors, led Orange Regional, in Middletown, N.Y., to award Dr. Pine its 2009 Physician Leadership Award, the first time a woman has been selected for the honor.
Dr. Pine, who spent almost five years as an internist with Genesee Health Service in Rochester, N.Y., after residency, didn't intend to embark on a long-term career in Middletown, but after fulfilling a contract position to develop Orange Regional's hospital medicine program, she was asked by the hospital to continue providing hospitalist services. She went on to form Hudson Valley Hospital Physicians in 2003. Since then, it has grown from three to 18 physicians, plus six support staff.
“I have a passion for my community hospital and I was in a position to raise the quality of care as leader of a hospitalist service,” Dr. Pine said. Her team also has improved post- discharge care at the hospital by hiring patient care and quality improvement coordinators.
Hudson Valley's two patient care coordinators work with physicians in the hospital to make sure that needed care, such as lab work, is being pushed forward on schedule. The company maintains a database of all factors known to increase length of stay and analyzes where care is falling short.
Quality coordinators pick up where patient care coordinators leave off by managing the post-discharge period. They track pending tests on the company's computer system and flag incoming test results for the primary care physician. They also keep tabs on whether patients return to their physicians for a first follow-up visit, and send reminders if they don't come back.
Perhaps most importantly, Dr. Pine ensures that physicians know how to work with these coordinators by requiring new physicians to go through a month-long training period.
“It's a huge operational loss because the physicians aren't bringing in revenue during that time,” said Dr. Pine. “But you get it back because when that doctor finishes training, they know how to bill, code, cut length of stay and use patient care coordinators.”
Dr. Pine's success at Orange Regional has prompted inquiries about expanding to other medical centers, but she hasn't been tempted so far. “I think people shouldn't judge themselves on how big their programs are or how many programs they can take over,” she said. “It's more important to ask, ‘What are you doing in the program that you have?’”
Hospitalist leads group from scrappy start-up to regional player
Scott C. Rissmiller, ACP Member
Medical school: Medical College of Georgia, Augusta, Ga.
Residency: Carolinas Medical Center, Charlotte, N.C.
Current position: Medical director, Carolinas Hospitalist Group, Charlotte, N.C.
Scott C. Rissmiller, ACP Member, has had a busy decade. In 2000, he helped launch a two-hospitalist operation at an outpatient medical group in Charlotte, N.C., and oversaw its growth into a 41-physician concern that today operates at four hospitals in the Carolina Healthcare System.
His rapid rise isn't surprising considering the successful initiatives he has helped launch over the past few years, including standardizing diabetes care across the Carolina Healthcare System (CHS) and championing a transitional program for heart failure patients. Dr. Rissmiller said he's driven by the belief that hospitalists play a pivotal role in managing patients' length of stay and improving the patient experience.
“The value the hospital gets from a hospitalist team is beyond profit-and-loss statements,” said Dr. Rissmiller, who is based at CHS’ Carolina Medical Center in Charlotte and oversees hospitalists at three other affiliated regional hospitals. “We are partners in making the hospital a better place through committee work and acting as physician champions.”
As physician champion for Carolina's CMC Link, a transition program for high-risk chronic heart failure patients, Dr. Rissmiller helped implement a post-discharge follow-up program that has significantly lowered these patients' readmission rates. Within 72 hours after an enrolled CHF patient leaves the hospital, a registered nurse calls the patient to discuss how to monitor his or her condition at home.
“The nurse periodically follows up with them from that point on,” Dr. Rissmiller explained. “If the patient's weight starts to go up significantly, the nurse relays that information back to the patient's primary care physician.”
Dr. Rissmiller is building on the success of CMC Link by championing a diuretic self-titration program. Under the new process, the patient follows a set protocol to adjust the diuretic dose at home if his or her weight starts increasing. Dr. Rissmiller's team works closely with outpatient physicians to keep more CHF patients at home and reduce readmissions.
“The highest risk is the time between discharge and follow-up with the patient's primary care physician,” Dr. Rissmiller observed. “If the patient doesn't get support, they are unclear about how to manage their condition and end up coming back.”
As impressive as his clinical accomplishments are, Dr. Rissmiller has received as much if not more praise for his administrative and leadership skills as medical director of the Charlotte-based Carolinas Hospitalist Group.
“Dr. Rissmiller used innovation and creativity to forge a unified hospitalist program out of many disparate pieces,” said Paul W. Hofferbert, ACP Member, one of three medical directors who report to Dr. Rissmiller.
Dr. Rissmiller, now in his ninth year with CMC, started a hospitalist team with one other physician, Brian Dalrymple, ACP Member, after completing his residency. In the beginning, the pair worked for a single multispecialty outpatient group in Charlotte but, as their reputation grew, other groups enlisted their services and Dr. Rissmiller and his partner hired eight more physicians. The group went through two more rapid expansions, once in 2005 when it became CMC's dedicated hospitalist group and again in 2007 when it expanded to all four CMC hospitals in the region. The group now has 41 physicians at four hospitals under Dr. Rissmiller's direction.
“Prior to 2007, the hospitalist programs at our four Charlotte-area hospitals were separate and were not integrated into Carolinas Healthcare System,” said Dr. Hofferbert, who nominated Dr. Rissmiller as a Top Hospitalist. “The [integration] process has required frequent changes in course and Dr. Rissmiller has succeeded by using input from the rank-and-file rather than a top-down approach. It is remarkable that not even three years later, we function as a unified entity.”
Fostering a team approach and understanding that retention is about much more than compensation have been critical to the group's ability to attract and retain high-quality physicians, Dr. Rissmiller said.
“People get into trouble when they have an independent contractor mentality where the doctors show up, do their work and go home,” said Dr. Rissmiller. “Our doctors feel like they have a voice and that their opinions matter. It's a challenge to keep the culture as we grow but that's what keeps us successful.”
Hospitalist's enthusiasm drives quality improvements at UCSF
Brad Sharpe, FACP
Medical school: Harvard Medical School, Boston
Residency: University of California, San Francisco, Medical Center
Current titles: Associate clinical professor and associate division chief, division of hospital medicine, UCSF; associate program director, UCSF internal medicine residency
Brad Sharpe, FACP, might have discovered the secret to getting doctors excited about quality improvement: Create a competition.
As chair of the UCSF Medical Center's performance improvement committee for community-acquired pneumonia (CAP), Dr. Sharpe was charged with instilling an evidence-based approach to caring for pneumonia patients based on Joint Commission Core Measures. Providing housestaff with the latest data on what was and wasn't working in CAP care was helpful, but the turning point came when he introduced the “Feather River Conference.”
“Feather River is a small hospital in northern California and, when we started doing this project, our quality numbers in CAP were worse than theirs,” explained Dr. Sharpe. “I told them that by some measures, Feather River was a better hospital than ours. Many things motivate physicians but pride in their institution, especially at a place like UCSF, is definitely one of them.”
Physicians at both hospitals enthusiastically embraced the challenge and it became a “big contest” that drew housestaff together in spirited competition, Dr. Sharpe said. As a result, the rate of appropriate antibiotic use at UCSF Medical Center rose from around 80% before the initiative to staying consistently above 90% after it was implemented.
The CAP initiative, combined with another grant-funded program co-led by Dr. Sharpe that promoted team-based care, led to an even more dramatic improvement in rates of preventive care for pneumonia. Screening and vaccination rates for the pneumococcal vaccine rose from less than 10% before these initiatives to near 90% currently.
Both projects appealed to Dr. Sharpe's interest in combining education with quality improvement and patient care. The team-based project, which brought together physicians, pharmacists and nurses for didactics, role playing, and small-group discussions, underscored the critical roles of good communication and collaboration in patient care, he said.
“It was eye opening to see how little the three disciplines understood each other,” Dr. Sharpe observed. “The most valuable part of the program was having people in the same room talking about patient care and learning what a day was like in each others' lives.”
Dr. Sharpe applies those lessons to his own work with residents. One of the best ways to be an effective teacher, he said, is to recognize your audience and respect them for who they are and the work they do.
“I try to channel my ‘inner student or intern’—to remember what it was like to be on call as an intern or doing my first oral case presentation as a medical student,” he said. “Part of that is getting my hands dirty and part of it is making sure I ask them how they are doing or what they want to learn about.”
The strategy is working, judging by Dr. Sharpe's teaching accolades. In addition to numerous other teaching awards, last year he was awarded the UCSF Distinction in Teaching Award, given to the most outstanding teacher at UCSF in the first five years on faculty.
Dr. Sharpe's teaching success made him a logical choice to co-lead the Academic Hospitalist Academy, a new initiative sponsored by the Society of General Internal Medicine, the Association of Chiefs of General Internal Medicine and the Society of Hospital Medicine aimed at training junior academic hospitalists. About 80 physicians from across the U.S. are expected to attend the first four-day session of the academy this month.
The Academy is an extension of what Dr. Sharpe most enjoys doing every day: helping people become better doctors.
“There's nothing quite like teaching someone and seeing them use those skills to better care for patients or teach someone else,” Dr. Sharpe said.
Missouri hospitalist program thrives as academic-commercial hybrid
Philip Vaidyan, FACP
Medical school: Medical College, Trivandrum, University of Kerala, Kerala, India
Residency: The Miriam Hospital, Brown University School of Medicine, Providence, R.I.
Current titles: Clinical assistant professor of medicine, St. Louis University, St. Louis, Mo.; director, hospital medicine, SSM St. Mary's Health Center; and practice group leader, IPC The Hospitalist Company
When Philip Vaidyan, FACP, was recruited to St. Mary's Health Center in St. Louis, Mo., his challenge was to build a hospital medicine program that met both its clinical needs and its internal medicine program's training requirements. His solution was an academic-commercial hybrid that's becoming a model of innovative care.
“We recognized that a private group would do a better job with the clinical piece but that we needed a separate contract with the department of medicine for teaching and administration,” said Dr. Vaidyan, now in his fourth year as director of hospital medicine at St. Mary's. As a result, a majority of the hospitalists at St. Mary's, including Dr. Vaidyan, are employed by IPC The Hospitalist Company while several also serve as faculty at St. Mary's Health Center's department of medicine.
“By being subsidized for my teaching by the department of medicine, I can do a better job because I'm not pressured to see as many patients,” said Dr. Vaidyan. The arrangement also improves resident education, he said, because educators are not as rushed at the bedside.
Before IPC came on board with this model, the hospital struggled because it lacked a good hospitalist program with which to partner and collaborate, he said. IPC has been able to provide hospitalists on demand and incorporate more sophisticated technology into billing and work processes. For example, IPC's Web-based discharge communication system allows physicians to create detailed summaries upon discharge that are immediately sent to patients' primary care physicians.
“There is so much fragmentation in the health system that a lot of patients go back to their primary care physician without vital information,” Dr. Vaidyan observed. “IPC's system generates a Web-based fax on the day of discharge containing all key information for the primary care physician so they have it when the patient shows up for a follow-up visit.”
Dr. Vaidyan has promoted a team-based approach to patient care by creating a dedicated hospitalist unit with a multidisciplinary patient management team and by integrating nurse practitioners (NPs) supervised by physicians to extend hours of hospitalist coverage from nine to 17 hours per day. Launched in June 2008, the hospitalist unit allows physicians to see patients in one place instead of running all over the hospital and promotes closer collaboration between physicians and nurses (ACP Hospitalist featured the program in its October 2008 issue) . Dr. Vaidyan also brought Project BOOST (Better Outcomes for Older adults though Safe Transition), a national quality improvement initiative focused on better transition from hospital to home, to St. Mary's by convincing the administration of its value and is leading its so far successful implementation.
The innovations have led to rising patient satisfaction, according to Press Ganey surveys, and the risk-adjusted 30-day readmission rate decreased by more than 15% over the past year.
Dr. Vaidyan also introduced a morning handoff conference attended by hospitalists, NPs, nursing team leaders, and unit-based care managers and social workers. He then initiated a now popular and effective twice-weekly multidisciplinary patient management conference, involving hospitalist MDs and NPs, medical residents, RNs, nurses' aides, case managers, social workers and clinical pharmacists. Besides improving patient care through better communication, the conference has instilled a sense of collegiality among staff and made physicians' schedules more predictable.
“It's been a huge cultural change in the hospital,” said Dr. Vaidyan. “Doctors don't have the kind of days where they have 25 new patients to see. We now have the ability to predict what our days will look like, which helps us feel less stressed out and prevents burnout and turnover.”
The hospitalist program is now considered a model of best practices by other hospitals in the region, said St. Mary's chief of medicine, Morey Gardner, ACP Member, who nominated Dr. Vaidyan as a Top Hospitalist. Dr. Vaidyan is also extremely popular among residents and other staff, he added. Dr. Vaidyan was voted “Teacher of the Year” by the internal medicine housestaff in 2008.
“Dr. Vaidyan, in five short years, has become recognized as one of the preeminent clinicians on our staff,” said Dr. Gardner. “His competent, dedicated and energetic leadership has resulted in dramatic accomplishments for our institution.”
Celebrated mentor inspires younger physicians to achieve their goals
Neil H. Winawer, ACP Member
Medical school: SUNY Downstate Medical Center, Brooklyn, N.Y.
Residency: New York University Medical Center/Bellevue Hospital, New York City
Current titles: Associate professor of medicine, Emory University School of Medicine; director, hospital medicine unit, Grady Memorial Hospital, Atlanta; and editor-in-chief, Journal Watch Hospital Medicine
Most educators consider recognition from their trainees and colleagues to be among the highest forms of praise. By that measure, 2009 has been a banner year for Neil H. Winawer, ACP Member, who has been singled out for top honors by the medical students, residents and young faculty he teaches and mentors.
“Teaching and mentoring are things that can't be forced,” observed Dr. Winawer. “As a mentor, I try to get someone involved with the things they're interested in and gently nudge them toward their goals.”
Longtime mentee Kimberly D. Manning, ACP Member, who nominated Dr. Winawer as a Top Hospitalist, calls her mentor “the ultimate teacher.” Since their mentoring relationship became official in 2005, Dr. Manning has published in prestigious research journals, won several teaching awards and uncovered a talent for communicating by becoming a TV medical news commentator.
“His guidance has absolutely changed the trajectory of my career,” said Dr. Manning. “Neil is a shining example of how mid-level faculty can rise to the occasion to lead, encourage, and grow junior members of the faculty into successful and productive clinician-educators.”
Dr. Manning's testimony led to Dr. Winawer receiving Emory's 2009 Silver Pear Mentoring Award for clinical faculty, given to the person who has demonstrated outstanding mentoring to early career faculty in the department of medicine. He was also voted Best Attending by the medical school class of 2009 and received the Juha P. Kokko Award for best teacher in Emory's department of medicine, one of the country's largest teaching programs covering four hospitals and over 100 housestaff.
Dr. Winawer, who became director of the hospital medicine unit six years ago, leads by example. Struck by inefficiencies in Grady's telemetry unit, he headed a task force and pushed through the Telemetry Urgent Matters Initiative (TUMI), transforming the way patients are managed and alleviating emergency department overcrowding. His approach involved two fundamental changes: creating a one-page form to simplify transfers off the unit and giving the unit directors final say over transfers based on set criteria for use of telemetry beds. The results were dramatic: Within a week of implementation, the number of patients moved off the unit went from 25 to 75.
“A lot of times doctors in training feel that by putting a patient on a monitor, they have another set of eyes watching the heart rate,” said Dr. Winawer. “But some indications [for telemetry] are not evidence-based and the service is clearly overutilized.”
TUMI was presented at a subsequent Society of Hospital Medicine meeting and published by the Agency for Healthcare Research and Quality as an example of an innovation that might help other institutions address the problem of ED overcrowding.
In addition to his clinical and teaching duties, Dr. Winawer volunteers as a television commentator on a local morning program. Since 2004, he's recorded more than 100 live episodes that broadcast to more than 100,000 viewers in the Atlanta area. He offers an expert opinion on medical topics in the news, such as trials for a swine flu vaccine.
Dr. Winawer enjoys the variety of clinical, research and teaching duties that his role requires. But he gets the most personal satisfaction from his success in educating and mentoring the next generation of hospitalists.
“The one thing this year that I was most proud of was being recognized for significant contributions [in teaching],” he said. “To have each level of my interactions with students, housestaff and faculty recognized was a real honor for me.”