I vividly recall attending a faculty meeting at San Francisco General Hospital in the mid-1990s, soon after I joined the UCSF faculty. Our late, great chief of medicine Merle Sande was chronicling all the recent and predicted changes in the healthcare landscape: managed care, more transparency, new regulations, and more. The meeting turned glum; we were not a change-oriented crowd, and this was a lot to swallow. When Mel Cheitlin, a beloved senior cardiologist, took the floor, everyone hushed – Mel could be counted on for 
grandfatherly wisdom when the going was tough.
“You know,” Mel said softly, “this could be worse.” We all looked up – our predicament seemed pretty terrible. Mel paused, and then continued.
“I could be younger,” he said.
I wish Mel could have joined me for last week’s annual meeting of the Society of Hospital Medicine in Washington D.C. He would have rethought his stance on aging. He might have even questioned his career choice.
While Beckman’s recent article and the follow-up letters (including one by me) in the Annals of Internal Medicine leave no doubt that there are still boatloads of non-believers, it is hard to come away from the SHM meeting and not be sold on the hospitalist field’s boundless possibilities.
Beyond being wowed by the sheer size of the crowd (2,500 this year, up from 1,600 two years ago), outside visitors to the SHM meeting are always struck by one thing: the “woe is me” chatter that dominates many physician conferences is vanishingly rare. Rather, the twin mantras are change and improvement, and the meeting’s content and hallway conversations reflect this. While the odd session is about billing or call schedules, the majority address topics like reengineering hospital care, smoothing transitions, building teams, enhancing physician-patient communication, implementing palliative care programs…. In short, our field has branded itself as being about improving the quality, safety, patient-centeredness, and efficiency of hospital care. It is way cool, and it couldn’t be timelier.
Of course, in April 2010 in DC, health reform was in the air. Opening keynote speaker, Beth Israel Deaconess CEO (and blogger) Paul Levy, admonished us not to get too distracted by the events in Washington, focusing instead on doing the right things for our patients. In a fascinating health policy panel, the always-insightful Ron Greeno, Cogent’s chief physician, was asked whether the formation of Accountable Care Organizations (ACOs) risks creating a situation in which “we’re colluding with hospitals to limit care.” “I hope so,” said Ron, tongue only partly in cheek as he emphasized the necessity of hospitalists and hospitals partnering to ethically but purposefully rationalize our unsustainable use of healthcare resources.
In my closing keynote, I spoke about the new terms introduced during the yearlong healthcare reform debate, such as ACOs, death panels, “bending the cost curve”, and bundled payments. I appreciate those hardy souls who stayed till the bitter end; for the rest of you (yes, I know, you needed to get home before volcanic ash entered your air space), I summarized the talk in an article in this month’s Journal of Hospital Medicine.
I received a special honor at the meeting: SHM inaugurated its first three “Masters”, and I was one of them (along with my dearfriends Win Whitcomb and John Nelson, the co-founders of SHM). It was very sweet, particularly since SHM’s outgoing president Scott Flanders, my former protégé (who now directs the hospitalist program at the University of Michigan), gave out the awards. After an introduction in which Scott offered me far too much credit for his fantastic career success, he recalled that I was the first non-family member to see his kids after they were born at UCSF. And then, to my astonishment, his completely adorable, towheaded kids jumped onstage, wearing “I Love Bob” tee shirts. Seeing folks like Scott succeed (he handed off the SHM presidential gavel to Tulane’s Jeff Wiese, another UCSF residency product) is the epitome of professional gratification.
Speaking of which, I hope you’ll forgive me if I gush a bit about my own team of UCSF hospitalists. About three years ago, I began to worry that we were starting to lose our mojo: young faculty seemed somewhat blue and overwhelmed, our recruitment fell off, and our productivity dipped. Soon after we held a retreat that morphed into a Root Cause Analysis of the problems, everyone snapped into action: we restructured job descriptions, our mid-career faculty stepped up their mentoring, we launched a research “incubator” and a superb faculty development program for our junior faculty, and we paid much more attention to everyone’s job satisfaction and our overall culture. The result: our division has reached new pinnacles of success, and happiness. At the SHM meeting, the fruits of these efforts were everywhere: Brad Sharpe, Margaret Fang, Niraj Sehgal, Arpana Vidyarthi, and Andy Auerbach all spoke at or chaired major sessions; Margaret won SHM’s 2010 top researcher award; and Brad, Niraj, Steve Pantilat, and Adrienne Green became Senior Fellows of the Society.
While I was absolutely thrilled by the accomplishments of our “senior” (heck, they’re all kids to me) faculty, I was even more pleased by the achievements of our fellows and junior faculty. We all joked about Mourad Wall, where Michelle displayed her 3 posters. Fellow Kirsten Kangelaris won SHM’s first-ever young researcher award (which came with a $50,000 grant), fellow Patrick Kneeland had an award winning clinical vignette with one of our residents Jenny Wie, and our other fellows, Chase Coffey, and Brad Butcher, had outstanding research presentations, as did several other of our junior faculty. (Pictures of UCSF at SHM are here.)
It was a great week, one that left me confident that our field will continue to make pivotal contributions to improving both individual patient care and the overall system, particularly as today’s young hospitalists grow into positions of local and national leadership. I can’t speak for you, Mel, but personally, I’d love to be younger.
I am a retired pathologist who “drank the performance improvement Koolaid” and was greatly frustrated by our community hospitals’ medical staff’s skepticism about this movement. Hospitalists, as you have so aptly stated, have an unprecedented opportunity to drive patient safety and process improvement,literally from the inside. However, they risk being lumped in with the rest of us hospital-based docs as pawns of the greedy administrations. I hope instead, they can serve as leaders and mentors of the medical staff as these needed changes are made.
Parenthetically,was that the Merle Sande from the University of Va.? He was chief of Infectious Disease while I was a resident at UVa. and was last author on my one and only publication, on an acid-fast variant of Legionella in the 70’s. I am sorry to learn he passed away.
Y
es, Bev, that is the very same Merle Sande, who, after leaving the University of Virginia, became the chief of medicine at San Francisco General Hospital (where he was the driving force behind the world’s first inpatient and outpatient AIDS units) and later chair of the department of medicine at the University of Utah. He was a giant in academic medicine, and a person who influenced hundreds of careers, including my own. He passed away in 2007, and is greatly missed by all who knew him.
Thank you for the update on Dr. Sande. Interestingly, my own mentor at UVa., Dr. Benjamin Sturgill of the pathology department, also died from multiple myeloma at a relatively young age.
To clarify my “pawns of the greedy administration” comment, I meant that the clinical physicians sometimes regard us as such, not that we actually are such – although I am sure there are hospital administrations who do attempt such things. It tends to diminish our credibility with the “outside” staff.
Health Care Reform Act-intent for Change
For many years, America’s health brokers have been offering health insurance to individuals, small businesses and large businesses for decades, yet the enrollment statistics have revealed a steady decrease on an annual basis. The number of uninsured Americans is estimated to be as high as 30 million, and the Health Care Reform Act offers a solution. Not only will there be a higher enrollment number for America’s health brokers, but as of 2014, it will be required by law for every American to obtain health insurance. Every single American will be impacted by the New Health Reform Bill, making it one of the most important measures of the 21st Century.
Businesses
The main focus will be on businesses of 50 or more employees, in which they will be required to offer individual health plans, as well as family plans to all employees or face some stiff fines from the government. The amount comes to $2000 per uninsured employee, though there are exemptions to this fine. If you as an employer assist an individual with acquiring a personal health insurance plan through an open market called an exchange, then it would result in no fines. This only applies to an individual who makes a certain amount under the Federal Poverty Level, and the premiums are over 8% of his annual income.
America’s health brokers can rest easy in the fact that there will be expanded coverage, though there may be more competition. With the rise in individuals who will have health insurance, there may not be as large of a risk as one may assume. Though the new bill will require America’s health brokers to enroll individuals with pre-existing conditions, there will also be a new population of young individuals who will be insured with fewer health problems.
It is understood that larger companies already provide a group insurance plan (HMO, PPO) that covers all areas of needs for the population of employees. These policies will change very little, but there may be some changes in where the funding for the new health care plan will come. It is proposed that those making a certain amount of money, both individuals and couples, will be taxed at a higher percentage than others. This will provide money that can be used for the exchange and making sure that all individuals will be offered an affordable health plan.
There are still a few years before the plan goes into full effect, though some of the measures will be enforced immediately. There will be plenty of time to sort out the details and iron out the difficulties. As for the plan, anyone who does not have health insurance as of January 1, 2014, will be penalized a certain amount of money, and this amount could become worse if health insurance is continuously neglected. There has never been a better opportunity for America’s health brokers in terms of acquiring a new customer base-a broader customer base. Also, there has never been a better time in history for individuals being provided with the resources for the necessary medical treatment. This is a very unique time, with history in the making. Finally, there will be health care for all.
Paul Levy’s comments exhorting hospitalists to stick to clinical medicine are particularly intriguing. Involvement in policy matters is a logical culmination of our multi-pronged contributions in other spheres – healthcare quality, patient safety and hospital committees.
Wonder if Paul will break his silence on recent issues at BIDMC. Would greatly increase his credibility
http://www.bostonherald.com/jobfind/news/healthcare/view/20100501paul_levy_wont_break_silence_beth_israel_chief_bars_reporter_from_ohio_conference/srvc=home&position=also