In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.1 As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.
The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).
Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.
No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.
Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).
It forces us to make sure the services we provide are meeting the customer’s expectations. We can and do learn from each other.
—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver
Purposeful, Team-Based Medicine
Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.
Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.
“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.