Forum Focus – Communication, collegiality, and care (part two of a two-part series)

By Bill O’Neill, Director of Outreach and Communications for the Center for Personalized Education for Physicians

Pitfalls and Perils on Medical Teams

In recent years, changes to the structure of medical teams, intended to improve communication, sometimes have the opposite effect. As medicine becomes more team-based and less hierarchical, some physicians may feel threatened. According to Matt Steinkamp, M.S.W., lead faculty for CPEP’s “Improving Inter-Professional Communications” seminar, “Physicians often tell me they have feelings of loss: loss of their role as a leader, loss of respect and prestige, and perceived loss of influence. These feelings can manifest as anger and frustration with their colleagues.”

By definition, the practice of medicine is a stressful endeavor, and stress can lead to friction on a medical team. Dr. Michael Yochelson, Chief Medical Officer at MedStar National Rehabilitation Hospital, notes, “As a physician leader, this is something you have to deal with perpetually, and it occurs with both attending physicians as well as residents. Sometimes the friction can be peer to peer, but other times it occurs between a physician and a nurse or even a patient. Unfortunately, physicians may be able to get away with behavior that other team members cannot. Many are highly trained in very specific sub-specialties and are difficult to replace.”

According to Steven Defossez, M.D., Vice President of Clinical Integration at the Massachusetts Hospital Association, “A busy work day or environment just accentuates a ‘head’s down’ focus on the task at hand and can heighten tensions with others. If you’re constantly in a hurry, you’re already set up for failure when it comes to inter-professional communication.”

Mr. Steinkamp agrees that time management, along with other factors, can complicate team dynamics. These include stylistic challenges, training issues and changes to the ways medical teams are structured. “Many physicians tend to be black and white, task-oriented, and can be perceived as ‘too direct,’ while nurses are often more process and relationship oriented. These styles can grate against one another,” Steinkamp reports.

Training issues, and the competitive nature of medical school and residency programs, may foster this “direct” style. Competitiveness, hard work and self-reliance are both required and rewarded, while teamwork may have been given a lower priority. When tempers flare, the words “I’m sorry” may be in short supply. Says CPEP’s Steinkamp, “Some physicians report apologizing is very difficult for them, and to some extent, have been trained not to as an admission of wrong-doing and an opening to liability.”

The Power of Relationships

In the face of these structural changes, Steinkamp suggests focusing on the “power of relationships” rather than on direct lines of authority. “Physicians can take steps to humanize themselves, bond with colleagues, educate vs. dictate, ask for input, and thus increase influence through ‘soft power.’”

Dr. Defossez adds, “You have to take the time to show you care about the people around you, and that can require trade-offs and motivation. Some individuals need to be convinced that by becoming more empathetic, effective communicators, they will in turn become more effective leaders. Interpersonal skills then become a useful tool, not just a ‘nice to have.’”

Dr. John Wald, Medical Director for Public Affairs at the Mayo Clinic, notes that embracing a team-based approach can lead to direct benefits for physicians. “Data shows that approximately 40% of physicians nationally report symptoms of burnout. An internal research group led by both physicians and nurses found that Mayo care groups that had a stronger team ethic reported reduced feelings of burnout, and thus greater job satisfaction.”

Strategies that Foster a Culture of Collegiality

Steinkamp encourages the use of team huddles as a way of assuring all hear the same thing at the same time and have an opportunity to get clarification. “You can’t just paper it over with a memo from the top. You need to lead by example and build these huddles into the daily schedule of medical teams – and then show up and engage. Scheduling huddles and then not attending can be more detrimental than not having a huddle to begin with.”

Dr. Defossez points to the Mayo Clinic’s primary value of “The needs of the patient always come first” as an example of a culture that promotes inter-professional teamwork. Dr. Wald agrees: “The Clinic was founded not only by the Mayo brothers, but also by the Sisters of St. Francis, who provided nursing and related care. The culture of mutual respect and partnership between physicians and staff was present from day one, and is still stressed today in every meeting at every level of the organization.”

Asked about team huddles, Dr. Wald notes, “These types of interactions are very common throughout the organization; some are formal, some informal. Pre-procedural/surgical huddles are a clinical requirement before any type of procedure, and all team members are encouraged to ask questions and make suggestions.”

Ed Eckenhoff, founder and president emeritus of the MedStar National Rehabilitation Hospital, maintains that the culture of teamwork is particularly strong in the rehabilitation hospital community: “We incorporate the team approach, where the entire clinical team meets together several times per week to discuss the patients’ successes and needs. It becomes this summary that assists communication between attending physicians, nurses and therapists. They all become quickly up–to-date with all aspects of patient care and appreciate each other as patient-centered team members.”

MedStar NRH’s Yochelson adds, “Health care in general is moving towards a model that rehabilitation hospitals have embraced since the 1940s. Our patients have unique needs. They require a team approach to care, and that close-knit, interdisciplinary approach is built into our training in residency. In other environments, physicians often talk to nurses, not with nurses. In the rehabilitation setting, that communication is more of a dialog and a two-way street. Nurses learn from physicians and vice-versa.”

The Challenge of Leadership

Dr. Yochelson continues: “These issues can be a real challenge to manage as a leader – nobody really likes, or wants, to deal with them. However, physician leaders have to resist the temptation to sweep these problems under the rug – they have to be dealt with in a serious manner. Leadership needs to sit down with the physician in question and be very candid; a physician may not have any idea how they come across, and that has to be made clear to them. Hopefully they will have the ability to change, although it may not happen overnight. These conversations may lead to education, coaching, or, if problems continue, discipline.”

“At MedStar NRH, we make it clear that regardless of title, all physicians are leaders and role models and are expected to act accordingly.”

About CPEP

CPEP (www.cpepdoc.org) is a 501 (c)(3) organization that promotes quality patient care and safety by enhancing the competence of physicians and other healthcare professionals in all 50 states from its offices in Denver, Colorado and Raleigh, North Carolina. CPEP offers focused courses on communication in the clinical environment, prescribing controlled drugs, and professional ethics as well as comprehensive clinical competence assessments.

Forum Focus – Bridging the gaps in effective communication (part one of a two-part series)

By Bill O’Neill, Director of Outreach and Communications for  the Center for Personalized Education for Physicians

The Physician Leadership Forum’s white paper, Lifelong Learning: Physician Competency Development, examines the ACGME/ABMS core competencies and identifies gaps between the perceived importance of each competency and the evidence that each is put to work in the hospital. The gap between importance and evidence was particularly apparent in one area: Interpersonal and Communications skills.

Everyone can agree on the importance of effective information exchange and the ability to work cooperatively in a health care team, but is everyone willing, or able, to devote the time and effort required for success in those areas? Evidence suggests there is still work to do. This article is the first of a two-part series, and will deal with the effective exchange of information on medical teams. While common pitfalls will be described, the real focus will be on improvement approaches for individuals, as well as strategies leaders can employ to create cultures of meaningful communication.

Effective Information Exchange via Effective Documentation

For the most part, effective information exchange in the hospital setting is accomplished through appropriate charting and record keeping. “Done well, documentation should serve multiple purposes: improving quality of care, patient safety, and institutional finances all at the same time,” said Dr. Joel Dickerman, Chief Medical Officer at Community Care in Colorado Springs, Colo. According to Dr. Dickerman, positive financial outcomes and effective documentation often go hand in hand. “Effective documentation contributes to effective transition of care, which in turn leads to reduced readmission rates and increased patient satisfaction – both metrics that improve patient care and reduce non-beneficial care,” he said.

Have Electronic Medical Records (EMR) Helped?

According to Dr. Dickerman, EMR systems do not always live up to their promise. If these systems are simply used to improve legibility and capture procedures and charges, they are not being utilized to their full potential. “EMR systems are tools, not solutions by themselves. Documentation should be viewed as a form of communication, not just a means of capturing charges and minimizing liability,” he said.

Dr. John Wald, Medical Director for Public Affairs at the Mayo Clinic, feels the structure of some EMR systems may contribute to this problem. “EMR systems do a good job capturing charges and documenting that various quality measures are being implemented (asking about smoking status, blood sugar control, etc.). Unfortunately, this can make a smooth narrative of patient care hard to find – and that can be problematic when there is a transition of care,” he said. As a result, he adds, “the architecture of these systems needs to evolve, making sure that clear, intuitive provider-to-provider communication is front and center in these systems.”

Never Enough Time…

Participants in CPEP’s Medical Record Keeping Seminar report that the biggest roadblock they face in improving documentation is time – a precious commodity in short supply. In addition to proactively building documentation time into the clinical schedule, Dr. Dickerman, the seminar’s program director, suggests hiring medical scribes as an effective approach. “The additional patients you see will more than pay for the service and allow you to be a doctor – not a typist,” he said. The American Health Information Management Association has a resource page devoted to medical scribes at http://bit.ly/145Gs36.

Strategies for Hospital Leaders – How to Improve Documentation at the System Level

Dr. Dickerman hypothesizes that the advent of value-based reimbursement may change the picture with its greater emphasis on quality of care, highlighting the value of effective documentation. He notes, however, “Some physicians may need to relearn lessons in professionalism and communication in such an environment.”

One way to encourage a new outlook on these issues is to put systems in place in which hospital and physician incentives are well aligned. While some hospitals are now reimbursed on a population health management basis, the physicians within those organizations may still be reimbursed on a volume-based, fee-for-service model. Improving the alignment of hospital and physician incentives will encourage physicians to view medical record keeping as an opportunity for ensuring and improving patient care rather than as a series of check boxes and drop-down menus that document individual procedures.

Dr. Katie Richardson, Director of Physician Experience at the Colorado Permanente Medical Group, notes, “At Kaiser Permanente, we’re incentivized to do what’s right for the patient, and our success is measured by the quality of our care, not by our productivity. We have medical informatics and communications teams that work closely together on training in oral and written communication/documentation, and the training is done almost exclusively by physicians. What’s more, our documentation skills are reviewed annually by our local physician leaders to ensure that each of us is communicating clearly with colleagues as well as patients in the After Care Summary – a Core Measure of meaningful use requirements.”

The Road Ahead: Transparency for Patients

In separate interviews, Kaiser Permanente’s Richardson and Mayo Clinic’s Wald independently noted the new reality of patients’ access to their data, and the subsequent demand for clear and cogent documentation. Dr. Wald notes, “Traditionally, the ultimate goal of EMR systems was clear communication with colleagues, ensuring smooth transition of care. More and more, however, patients demand greater access to their information and so clear documentation needs to speak to them as well.” Dr. Richardson concurs, “Full transparency of medical records with our patients is coming. As patients gain full access to their information, the responsibility for creating clear and meaningful stories of care will only grow more acute.”

Conclusion

The effective exchange of information through appropriate record keeping is a challenge for individuals and institutions alike. However, access to available educational resources, combined with innovative strategies driven by committed physician leadership can improve quality of care, reduce the risk of medical error and make measurable improvements to the financial health of health care institutions.

About the Author

Bill O’Neill is Director of Outreach and Communications for CPEP, the Center for Personalized Education for Physicians (www.cpepdoc.org). CPEP is a 501 (c)(3) organization offering comprehensive clinical competence assessments, customized education plans for physicians, and focused educational programs including Medical Record Keeping, Improving Interprofessional Communication, Prescribing Controlled Drugs, and ProBE (Problem-Based Professional Ethics).

Forum Focus – Physician payment reform and the SGR fix

After 18 years and 17 “temporary” patches, Congress finally passed legislation – the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – earlier this spring to permanently repeal and replace the Medicare physician sustainable growth rate (SGR). The SGR fix and its implications for physician payment were the subject of a recent Physician Leadership Forum webinar.

The SGR formula was replaced with specified payment updates. For the next four years, Centers for Medicare & Medicaid Services (CMS) will apply an annual update of 0.5 percent to the physician fee schedule. Beginning in 2019, payment rates will remain flat, and physicians and providers paid under the physician fee schedule must choose whether to be paid under a merit-based incentive payment system (MIPS) or through alternative payment models (APMs).

The MIPS will tie physician payment directly to performance measurement. MACRA sunsets the current-law physician quality reporting system, meaningful use and value-based modifier programs and incorporates the measures and processes for these programs into the MIPS. Professionals’ performance will be assessed in four specific areas: quality, resource use, clinical practice improvement activities and meaningful use of electronic health records (EHRs). That performance will then be used to determine a payment adjustment. The payment adjustment – in the form of bonuses for high performer and penalties for poor performers – will be assessed on a sliding scale and capped at +/- 4 percent in 2019; +/- 5 percent in 2020; +/- 7 percent in 2021; and +/- 9 percent in 2022 and subsequent years.

As an alternative, physicians and other professionals who receive a significant proportion of their payments through an entity that participates in a qualifying APM, such as the Medicare Shared Savings Program, will earn an additional 5 percent payment each year from 2019 through 2024. In addition, beginning in 2019, qualifying APM participants are exempt from the MIPS, as well as most EHR meaningful use requirements. A qualifying APM entity must require use of a certified EHR, bear more than nominal risk for financial loss, and tie payments to APM participants based on quality measures comparable to those used in the MIPs.

Bryan Gamble, MD, MS, FACS, president and CEO of the Florida Hospital Medical Group, discussed the work his medical group has done to manage the clinical and financial risk in alternative payment models. He discussed the different categories of payment and how a larger percentage of Medicare fee-for-service payments will be linked to quality and APMs. He said his group is focusing on the way they deliver care, following the Triple Aim of improving the health of the population, improving the quality of care they receive all while reducing costs.

Gamble described other factors driving change and dollars in the marketplace such as value-based payments and a movement from inpatient to ambulatory space. He especially underscored the increasing role of consumerism in health care. He said patients are looking for convenience in handling their health care needs. They’re interested in technology and connectivity. In the near term, he said compensation will be determined on a number of issues such as coding accuracy/audits, as well as Stark Law implications, fair market value, commercial reasonableness, and designated health services.

For more on this issue, see our webinar SGR Fix: Implications for Physician Payment.

Forum Focus – AONE Toolkit and Guiding Principles on Mitigating Violence in the Workplace

Workplace violence is an increasingly recognized safety issue in the health care community. In 2010, the Bureau of Labor Statistics data reported health care and social assistance workers were the victims of approximately 11,370 assaults by persons. While workplace violence against health care professionals can and does happen everywhere, the hospital emergency department is among the most vulnerable settings. According to a 2011 study by the Emergency Nurses Association (ENA), 54.5 percent out of 6,504 emergency nurses experienced physical violence and/or verbal abuse from a patient and/or visitor during the past week. The actual rate of incidences of violence is much higher as many incidents go unreported.

Concerned about the issue, members of the American Organization of Nurse Executives (AONE) and ENA met to discuss how incidents of violence are currently addressed in hospitals and the need to create an environment where health care professionals, patients and families feel safe. A culture change is also needed so violence against health care professionals is no longer viewed as “part of the job.”

The outcome of the meeting was the development of guiding principles and a tool kit to assist nurse leaders in systematically addressing measures to manage and reduce violence against health care professionals in hospitals.

Guiding Principles and Priorities

The guiding principles are steps to systematically reduce lateral, as well as patient and family violence in the work place. These include recognizing that violence can and does happen everywhere, requiring an interdisciplinary team, which includes patients and families, to address workplace violence, and that addressing workplace violence may increase the effectiveness of nursing practice and patient care.

The priority areas delve deeper into the guiding principles, focusing on five areas critical to a successful workplace violence prevention program. They challenge organizations to take a closer look at their social environments, figure out how hazards can be addressed and what training may be required to mitigate them, and devise a way to measure success.

Toolkit

The toolkit provides step-by-step procedures for customizing a violence prevention plan for organizations, as well as templates to document progress. It begins with defining what constitutes workplace violence and providing resources for organizations to develop a zero-tolerance policy. It next shows organizations how to assess the risk factors in their facilities and develop a workplace violence prevention plan. It also offers a number of resources organizations can utilize to train and deploy staff to recognize what isn’t acceptable and what to do if they witness workplace violence. Lastly, it provides resources organizations can use to evaluate the changes and identify next steps in the process.

To download the toolkit and guiding principles, visit www.aone.org/workplaceviolence.

Forum Focus – The skills doctors and nurses need to be effective executives

This article originally appeared on the Harvard Business Review (www.hbr.org) on April 7, 2015.

By Sachin H. Jain, MD

We are witnessing an unprecedented transformation of the health care industry. There has been a rapid growth in jobs and an explosion in the number of start-ups. There are new types of insurance companies such as Oscar; novel provider organizations such as OneMedical, IoraHealth, and ChenMed; and new health information technology companies such as Castlight, Vital, and WellFrame that aim to use technology to improve care and value. Physicians and nurses are being called upon to lead these new health care enterprises — and are assuming a higher level of influence in the business of health care than ever before.

Maximizing the effectiveness of physicians and nurses in these new positions, however, will require different skills than the ones they developed during their clinical training. Having managed or worked with clinical leaders in care-delivery organizations, the pharmaceutical industry, and government, I have observed three skills that are critical to the success of doctors and nurses as they make the transition to management:

Operations management and execution. Many physicians and nurses excel at operations management because it requires the same kind of detail and complexity that is required to effectively manage a large clinical load.  In clinical work, we must constantly triage patients and parse significant amounts of low and high-level detail. Many clinicians manage a small operation in the form of their own clinical practice or ward before shifting to leading larger operations.

Still, many clinicians struggle with operations management because they fail to appropriately distinguish between urgent tasks and important, non-urgent tasks — often letting the latter fall by the wayside in favor of the former. Just as a first-year resident physician or a fresh nursing graduate must learn to manage his or her own workflows and develop a plan of attack to manage a patient’s issues, so too must a new clinician executive learn to act with urgency and ownership to build an organization’s workflows and address its problems. Clinician leaders should recognize this potential gap in perspective and work actively to make sure that tasks are appropriately triaged by priority level.

People leadership. When thrust into a management or leadership position, many clinicians have never hired or fired anyone in their life. The instincts crucial to deciding whom to hire and how to hire them managing others’ performance are often underdeveloped in clinical leaders. For example, many clinicians, by nature and by training, are kind and compassionate. While these qualities help engender loyalty, they often make some of the difficult conversations associated with managing people especially challenging.

To accelerate the development of their people-management skills, clinicians should partner closely with fellow business leaders and HR professionals. These colleagues can be instrumental in helping them surface their needs and identify tactics to build and manage high-performance teams. These colleagues can also serve as sounding boards when they must make hard decisions and hold inevitable hard conversations.

Setting and defining strategy. Many clinician leaders are drawn to roles in which they can actively work to define organizational structure and strategy. While strategy roles often tap the strengths and deep frontline knowledge of clinicians, executives with clinician backgrounds often forget that creating a strategy involves making trade-offs. The decision to pursue one set of activities is often a decision not to pursue another. Strategy guru and Michael Porter of Harvard Business School elegantly articulated this when he wrote that strategy is both what we choose to do — and what we choose not to do. Clinicians must work to develop organizational strategies with this simple and important maxim constantly in mind.

One CEO with whom I have worked remarked that physicians and nurses run the risk of losing their clinical identities as they develop into executives. It would be a shame if they did. As they transition to careers in the business of health care, clinicians must hold on to the heart and practice of medicine as they continuously develop the core executive skills required to effectively lead and shape their organizations. Health care will be markedly better for it.

sachin_jain2
Sachin H. Jain, MD, is chief medical officer of the CareMore Health System, a division of Anthem, Inc., and a lecturer in health care policy at Harvard Medical School. Follow him on Twitter at @sacjai.

Forum Focus – Recognizing and Addressing Physician Stress and Burnout to Improve Satisfaction and Patient Care

By Alan H. Rosenstein MD, MBA, Michael R. Privitera MD, MS

There are a growing number of surveys and reports attesting to the increasing amount of stress and burnout impacting physicians in today’s health care environment, affecting nearly 80% of practicing physicians.1 The downstream impact of protracted stress and burnout can lead to a number of problems ranging from dissatisfaction, frustration, and anger, to more serious physical and emotional states that affect behavior and can compromise work relationships and patient care.2,3 While many organizations are beginning to recognize the impact of stress and burnout on satisfaction, productivity, care coordination, and clinical performance, there are still a number of barriers that need to be resolved.

First is the issue of perception. Many physicians are working at full capacity but may not recognize that their mind and body are working under stress. The cultural norm in pre-med, medical school, and residency is to push oneself beyond usual human abilities. Usual human feedback systems are often suppressed, and even when physicians realize stress may be taking a toll, many choose to handle it themselves and are often reluctant to seek outside help because of self- ego, stoicism, questions about competency, or concerns about confidentiality. Often problems related to stress are only addressed after a career-changing decision or disruptive event occurs where intervention may be focused more on damage control than emotional support.

The second issue is that of organizational response. With the changing priorities and incentives in today’s health care market many organizations are faced with increasing demands on physicians and supporting staff to meet the evolving challenges of health care delivery. Providers have their own concerns and at times feel that changes are being made without an opportunity for their input or discussion. Organizations need to be mindful of physician and staff concerns and take a leadership role in educating, involving, and engaging clinical staff in organizational decisions.

The third issue is socio-political perception. Patient safety initiatives and the Triple Aim efforts of improving the experience of care, improving the health of populations, and reducing per capita costs of health care may have unintentionally overlooked supporting the clinicians providing the care. Hospitals and health systems have had to rapidly adjust to uncoordinated mandates from multiple sources. Until recently, the trickle down incremental, cumulative effect on physicians and staff had been unrecognized as a major source of occupational stress. Reduction and prevention of physician occupational stress and burnout is beginning to be recognized as a patient safety concern and included in patient advocacy efforts.4 Recently, organizations such as The Joint Commission, National Patient Safety Foundation, and the American Hospital Association published recognition of the need to reduce stress and burnout.5-7

We have several recommendations. First is that the health care organizations recognize the need to support clinical staff to meet regulatory requirements while reducing occupational stress and sustaining wellbeing. The next step is to assess the current status of physician morale. Provide opportunities for physician input and involvement focused on ways to help them succeed. Surveys can help gather needed site-specific information. Inquiry should invite candid feedback about the positives and stressors of the work environment as well as actionable solutions. Results should be shared in aggregate form with management, physicians, and staff in a timely way to enhance trust through transparency. Using the results in future meetings can develop dialogue needed to encourage creative solutions. Using these dialogues as a basis, organizations can begin to provide education about the changing priorities and accountabilities in care delivery and work collaboratively with clinicians to pursue the mutual goal of providing appropriate, effective, high quality, safe, and satisfying patient care.

Maybe what’s most important is to provide the physician with emotional support. At one end is the issue of educating them about the dynamics surrounding health care delivery. Increasing awareness will increase understanding, which will lead to improved compliance and more satisfactory and effective hospital- physician- staff- patient relationships. Another level is to provide them with the skill sets to be more effective communicators and collaborators to enhance staff and patient relationships and satisfaction. Providing additional programs that focus on diversity management, cultural competency, Emotional Intelligence, stress, anger, or conflict management are helpful in improving behavioral compliance. In some cases individual coaching and counseling may be necessary which might be offered internally through Human Resources, Wellness Committees, a Physician EAP (Employee Assistance Program), or outsourced to a specialty vendor. In some cases, disciplinary action must be taken to address behaviors that could compromise patient care.8

We are all in this together. Physicians and all clinical staff are a precious resource whose focus is to deliver the best care. Hence, it is essential that the healthcare system administration, clinicians, and staff be seen as a team that through collaboration and aligned goals provides the best care possible to their community.

  1. Physician Stress and Burnout Survey 2015 Cejka Search and VITAL WorkLife Report VITALWorkLife.com/survey/Stress.
  2. Danielson, D., Ketterling, R., Rosenstein, A. “M.D Physician Stress and Burnout: Causes, Effects, and Impact on Performance and Behavior AMGA Group Practice Journal Vol.62 No.3 March 2013 p.38-41.
  3. Rosenstein, A. “Physician Stress and Burnout: What Can We Do?” American College of Physician Executives Vol.38 No.6 November/ December 2012 p.22-30.
  4. Privitera, M., Rosenstein, A., Plessow, F., LoCastro, T. “Physician Burnout and Occupational Stress: An Inconvenient Truth with Unintended Consequences” Journal of Hospital Administration Vol.4 No.1 December 2014 p.27-35.
  5. National Patient Safety Foundation, “Patient Safety News and Resources” https://npsf.site-ym.com/?page=January2015ENews.
  6. The Joint Commission, “Physician Leader Monthly” http://www.jointcommission.org/jc_physician_blog/the_impact_of_physician_burnout/.
  7. American Hospital Association, “Physician Leadership Forum” http://www.ahaphysicianforum.org/news/index.shtml.
  8. Rosenstein, A. “Bad Medicine: Managing the Risks of Disruptive Behaviors in Health Care Settings” Risk Management Vol.60 No.10 December 2013 p.38-42.

For more information, contact Alan H. Rosenstein MD, MBA, at ahrosensteinmd@aol.com.

Forum Focus – Back in the saddle again: The value of reentry physicians to hospital systems

By Bill O’Neill, Director of Outreach & Communications, Reentry to Clinical Practice Program, CPEP – The Center for Personalized Education for Physicians

 

“When a patient is newly covered by Medicaid, that doesn’t guarantee a primary care doctor will take them on – and they often end up coming to us. Our ER traffic increased 10% between 2013 and 2014.”

Greg D’Argonne
Chief Financial Officer of HCA-HealthONE and the HCA Continental Division

 

By now, the growing shortage of physicians in the United States has become common knowledge. “Geographic maldistribution” issues compound the problem. Some fortunate regions have an abundance of physicians, while others fall far short. HCA’s D’Argonne adds “The supply of physicians varies a lot depending upon the community. Lots of people want to move to Denver for the climate and lifestyle, so there really isn’t a noticeable shortage here. On the flip side, smaller cities without those advantages can face a very different situation.”

Changing Models, Changing Needs

The historical model of reimbursement in which incentives are aligned with increasing volume of procedures and services is fading fast. David Watson, Chief Medical Officer of the Centura Health Physician Group, comments, “Health systems are moving to managing population health in an ever increasing manner. Population health is best served at the primary care level and the supply of PCPs is insufficient to meet demand. The need to increase the number of providers, especially in the primary care field, is likely not going to stabilize for well over a decade.”

So what to do about these issues? Expanding the number of physicians by increasing the number of Medicare-supported residency programs may be an option, but federal budget scenarios are tight and developing new slots could take years. Working to grow the number of allied healthcare providers – PAs and NPs – can also help, but those providers are limited in the types of cases they manage.

Reentry Physicians as a Partial Solution

“Reentry physicians are like a ‘rapid deployment force’ – a relatively quick way to expand the number of practicing physicians when compared to expanding the medical school-residency-fellowship pipeline.”

Steven Summer
President and CEO of the Colorado Hospital Association

“Reentry” applies only to clinicians who left practice voluntarily for two years or more due to a variety of reasons, such as family obligations, personal health reasons, alternate careers, or retirement, and wish to return to the workforce to practice in the same specialty. The term does not apply to those who left practice for disciplinary reasons.

A lot can happen in a physicians’ life – and in the medical world – while he or she is away from patient care. Physicians may be required to demonstrate competence in order to obtain a medical license or join a practice. The clinician may choose to participate in a formal reentry training program, such as the program offered by CPEP, or engage in a self-managed reentry process.

“The literature indicates there is often a gap between a physician’s opinion of his or her competence vs. the results of an objective, third-party assessment. Working with an established, structured assessment and education program may result in the best outcomes for reentry physicians their prospective employers, and most importantly their patients.”

Scott Kirby, M.D.
Medical Director, North Carolina Medical Board

There are a handful of formal reentry programs across the country providing evaluation and education services. The length, activities, and cost of these programs vary. Established in 2003, CPEP’s Reentry to Clinical Practice (RCP) program is one of the original programs in the field. Through the RCP Program, participants complete an educational needs assessment in clinical skills and medical knowledge and an educational plan is developed. These structured plans include focused study, precepted education, and resumption of clinical activities under gradually decreasing levels of oversight. Once the clinician successfully completes the Reentry Plan, they receive documentation from CPEP summarizing their reentry efforts and their preparation for independent practice.

Conclusion

While physician shortages are major problems that lack easy solutions, hospital systems and group practices should explore the potential benefits of hosting reentry physicians in a preceptor setting. These candidates are experienced, highly motivated clinicians who can provide significant economic benefit to their hosts while bringing much-needed services to the communities in which they live.

Additional Resources

To download a copy of “The Roadmap to Reentry” developed by CPEP and the American Academy of Pediatrics, click here.

To access directories of structured reentry programs, visit the Physician Reentry to the Workforce Project website.

About CPEP and RCP

CPEP is a 501 (c)(3) organization that works to promote quality patient care and safety by enhancing the competence of physicians and other healthcare professionals in all 50 states from its offices in Denver, Colorado and Raleigh, North Carolina. CPEP’s RCP program has had a broad impact since its inception, with over 150 physicians from states enrolled in the Clinical Practice Reentry Program since 2003.