Inpatient Practice

The Documentation Game

board-gameOur hospital finished the last year with an inpatient mortality index of 0.54, a fantastic accomplishment. That means that we provide great care and we play the documentation game well. If the hospital mortality index is 1.0, that means that you had exactly the number of inpatient deaths that other hospitals have on average, after those patients are adjusted for their case mix index (CMI; a way of quantifying how sick the patients are). If your mortality index is > 1.0, then you had more deaths than the average hospital and if it is < 1.0, then you had fewer deaths than average. Another way of stating this is that the mortality index is the ratio of observed: expected mortality. At 0.54, our mortality index is one of the lowest of all hospitals in the country.

There are two ways you can keep your mortality index down: you can have few deaths (observed mortality) or you can document that you take care of a lot of sick patients. The best performing hospitals do both. As an example, your mortality index will be high if you have a young patient who came in for an elective cholecystectomy die (low expected mortality). On the other hand, if you have a 90-year old who has leukemia, is in heart failure, and is on dialysis come in for an emergent appendectomy and he dies (high expected mortality), your mortality index does not go up so much.

So if you want to be a best-performing hospital with a low mortality index, it is not good enough to just take great care of your patients, you have to document how sick they are. That’s where documenting secondary diagnoses that are present on admission becomes critical… and that’s where most physicians fall short. The hospital coders have to be able to pick those diagnoses out of the admission history and physical examination so it is necessary that the history and physical exam contain the precise words that indicate those secondary diagnoses that can significantly impact the case mix index. Words matter: you can’t just write “potassium = 3.0, will give KCl”, you have to actually write “hypokalemia, will give KCl”.

Here are the top secondary diagnoses that affect the expected mortality score:

  1. Anemia (specific type of anemia and whether it is acute or chronic)
  2. Acute respiratory failure
  3. Coagulopathy (including use of anticoagulants)
  4. Heart failure (systolic or diastolic; acute or chronic)
  5. Chronic kidney disease (including the stage number)
  6. End-stage renal disease
  7. Diabetes (including whether it is type I or type II, controlled or uncontrolled, and what organs have manifested complications)
  8. Hyperkalemia
  9. Hypokalemia
  10. Hypochloremia
  11. Hypomagnesemia
  12. Hypophosphatemia
  13. Hyperphosphatemia
  14. Hypocalcemia
  15. Hypercalcemia
  16. Hyponatremia
  17. Hypernatremia
  18. Dehydration
  19. Hepatitis (A, B, or C; acute or chronic)
  20. Liver disease
  21. Protein calorie malnutrition (mild, moderate, or severe)
  22. Metastatic cancer (including what organ it metastasized to)
  23. Decubitus ulcer (including the stage number)
  24. Pleural effusion
  25. Pulmonary edema
  26. Neurological or brain/spinal conditions
  27. Sepsis
  28. Shock
  29. Transfer from an acute care setting
  30. Requiring mechanical ventilation

We were all trained in medical school that the history and physical examination was all about our diagnostic impression and medical management. But the H&P is additionally an integral part of the documentation game. In the documentation game, the physicians are the players for the hospital and the physician gets more points for the more secondary diagnoses he or she documents. The winner is the hospital that documents that its patients are really, really sick and then discharges them alive.

October 29, 2016

Life In The Hospital

Electronic Medical Record Translation Guide

For those of you who are new to electronic medical records, you will be learning a new language used by physicians who use electronic medical records. This quick guide will help you translate into English:

When the physician says:        The physician means:

@*#$(^*@                             Would you be so kind as to help me route this encounter?

*$@!!($##*                             I find the communication management function to be satisfyingly easy to use.

)#@@**&!                             Pardon me but could you please assist me in unburdening my inbasket with several of these fascinating communications?

*@##@#!!                              I woke up last night and was unable to fall back to sleep since I was giddy with excitement looking forward to come in to work and use the electronic medical record this morning.

*#^%@*$$                             So sorry, but I appear to have used excessive force on my return button; could I impose upon you to replace my keyboard?

/#**!!@*!                                The beautifully flowing prose that I am able to now create using the electronic medical record is like poetry and brings tears to my eyes every time I read my own progress notes.

#!**@#!?$                              While I was working on my SmartPhrases, my coffee mug has inexplicably been found to be protruding from my monitor screen.

&%@#!*!!#                            My computer seems to have fallen out of my window; might you obtain a new one for me?

!*#@!&^!**                            I dearly love this new system and I am so appreciative that I no longer have to dictate my letters.

October 27, 2016

Life In The Hospital

Necktie, Vector Tie

necktieIf you know me, then you know that I usually don’t wear a tie at work. For most businessmen, a tie is a necessary fashion accessory to the male work wardrobe. For me, it is a device to transfer bacteria from one to another patient.

Studies have shown that 50% of physician’s ties are contaminated by potentially pathogenic bacteria, like methicillin-resistant Staphylococcus aureus (MRSA). They dangle in all kinds of stuff when we lean forward to examine patients and we almost never clean them (come on guys, when was the last time you dropped off a couple of dozen ties at the dry cleaner?). In the United Kingdom in 2007, many hospitals took the issue of physician’s neckties to heart and prohibited them from being worn in the hospital. So why do we keep wearing them?

The men’s necktie has its origins during the 1600’s when Croatian mercenaries working for the French army during the Thirty Years’ War had a habit of knotting a handkerchief around their necks. The French picked up on it and called the knotted cloths “Croats” which got turned into “cravats”, King Louis XIV took it one step further and knotted a piece of lace around his neck and like wildfire, it became the rage all across Europe. The necktie as a fashion statement stuck and we’ve been wearing them ever since.

But neckties can do bad things to you. If they are too tight, they can make your glaucoma worse. If they get caught up in a piece of machinery, they can strangle you. And if someone wants to do you harm, grabbing you by the tie is a really easy way to do it (probably why then NFL dropped the necktie from the game-day uniform of running backs).

In our hospital, we require anyone going into and out of a patient room to sanitize their hands with alcohol hand sanitizer that we keep on the corridor walls every 10 feet or so. But so far, we haven’t invented necktie sanitizers to use after patient encounters.

Personally, I never got the whole necktie fashion thing. I always thought that they were kind of uncomfortable and were always getting in my way. So when I read the recent articles on bacterial colonization of physician ties, I rejoiced because I now finally have an excuse to not wear a tie to work.

October 23, 2016

Emergency Department

Guns, Guns, Guns

gunYesterday, a man was shot a couple of miles from our hospital. Not an unusual event, people get shot every day in America’s large cities. Our hospital is not a designated trauma center but we still have gunshot victims dropped off at our front lobby by their friends – either they die in our ER or we stabilize them and send them to one of the regional trauma centers in Columbus. Guns are a way of life in our city, as they are in all cities in the U.S. We require all patients to go through metal detectors to get into the emergency department – as do all hospitals in town – and finding guns is not uncommon at the metal detector. We require anyone with a weapon to hand it over to our security personnel until they leave – a lot like an old west saloon.

Shootings and murder are commonplace in the United States. We kill each other more than any other first world nation and we are right up there with third world countries where a murder doesn’t even make headlines. We’re pretty good at the detective work that goes into solving those murders, our problem is that we just have too many of them.



To kill a person, two things have to happen. There has to be someone who wants to kill someone else and they have to have an effective way of killing. So, if killing another person requires both intent and an available method, which of these is the reason for the United State’s exceptionally high murder rate compared to peer countries? I’d like to think that it is not because Americans are full of more hatred than other industrialized nations.

A gun is a highly effective way to kill someone and we have too many of them. Guns are everywhere in the United States. We have more guns per capita than any other country on earth. In fact, we have more guns than we have people in our country.


What is the answer? I’m not any smarter than anyone else. But solutions need to start with what we agree on instead of starting with what we disagree on.

I think everyone in the U.S. would agree that a person shouldn’t be able to walk into a sporting goods store and by a nuclear weapon. But almost everyone would agree that a person who wants to go duck hunting should be able to buy a shotgun.

Everyone would agree that someone who was previously convicted of felony armed robbery and is also a card-carrying member of a terrorist group should not be allowed to buy guns. But almost everyone would agree that a law abiding citizen with no criminal record should be allowed to buy a gun.

We agree with the extremes of gun control. What we disagree with is where the line needs to be drawn in the middle. By spending all of our political energy on fighting each other in courts and legislatures about exactly where that middle line is for gun control, we’ve accomplished almost nothing. If we instead started with the fringes of the gun control debate and tried to figure out on what we can agree on, we might actually get something accomplished.

Don’t get me wrong. I’m not a raging liberal out to pry guns from everyone’s hands. I used to be a member of the NRA (when I perceived it as being an organization primarily dedicated to gun safety and recreational hunting rather than a lobby group for gun ownership). Some of my fondest memories from childhood were bird hunting with my father in early winter in rural Southern Ohio. And I’ve personally annihilated hundreds of clay pigeons over the decades (with permanent tinnitus as evidence).

But having too many guns and putting them in the hands of the wrong people just creates a lot more work for all of us who keep America’s hospitals working. As it is right now, we just make it too easy to kill each other in our country. For most of Americans, the topic of gun control is polarizing. But if you work in an emergency department or a trauma operating room, the lack of gun control is just exhausting.

Sorry to be up on a soap box about this. But we have to make steps to stop our country from being the murder capital of the Western World. I would much prefer my hospital to focus on treating disease than treating the consequences of motive + opportunity.

October 18, 2016

Life In The Hospital

The Sports Page

reinikka_reading_the_newspaperLast week, we filmed one of Ohio State’s MedNet-21 webcasts, this one on Environmental Emergencies. One of the topics was hypothermia and one of the presenters, Dr. Nick Kman from OSU, made the comment that “a hypothermic patient is not dead until they are warm and dead”. That reminded me of when I was taught that a patient is not dead until you read the sports page.

I was a 4th year medical student and was doing a rotation in general internal medicine with Dr. Bob Murnane who was a very highly esteemed internist in private practice in Columbus. He had an old-school medical practice: he had a solo practice, his office was across the street from the hospital, and he took care of all of his admitted patients on his own service in the hospital.

One morning, I arrived at his outpatient office. His nurse said Dr. Murnane was over at the hospital after getting stat-paged about one of his patients who had just taken a critical turn. He had told the nurse that we should get over to the patient’s room right away. The other medical student and I ran across the street, ran up the stairs and burst into the patient’s room, both of us out of breath.

We were expecting resuscitation efforts to be underway but when we opened the door, there was Dr. Murnane sitting in a chair in the patient’s room, calmly reading a newspaper. On the other side of the room, laying in bed, was the patient, an elderly lady with advanced dementia who had been admitted with pneumonia. And she looked, well… dead.

Without putting down the paper or looking up, Dr. Murnane said, “sit down boys, it’ll be a few minutes yet”. So we sat down and for about 5 minutes, there was not a sound in the room, except for Dr. Murnane turning the pages of the sports section of the morning newspaper. Finally, he put the paper down, walked over to the patient’s bed, checked her pulse, and said “Yep, she’s dead”.

He went on to say that he never pronounces a patient dead until he reads the sports page.

It turns out that a couple of decades earlier, he pronounced a patient dead who didn’t appear to be breathing and didn’t seem to have a pulse but after the patient had been taken to the morgue, he sat up, very much alive wanting to know why he wasn’t in his hospital room. So ever since, whenever a patient seemed to be dead, Dr. Murnane would check for a pulse and check for spontaneous breathing. Then he’d sit down and read the sports page and when he got done, if the patient still didn’t have a pulse or respirations, then he’d pronounce him dead.

Well, I thought that was just another idiosyncratic Murnane-ism until 4 years later when I was a pulmonary fellow in the MICU. We had a patient with severe COPD who had respiratory failure and was on a ventilator. He got progressively more bradycardia and hypotensive and the family decided against CPR. I was tied up doing a bedside procedure on another patient and so the attending physician was managing this particular patient. Eventually, the patient became asystolic so the attending physician pronounced him dead and the nurses disconnected him from the cardiac monitor and extubated him so the family could spend some time in the room before he was sent down to the morgue.

About 5 minutes after the family went in, they started shrieking and yelling that it was a miracle and he had arisen from the dead. One of his children had a camera and snapped a picture of the guy just as he sat up in bed with a shocked wide-eyed, open-mouthed expression on his face. The next week, that picture was on the front page of the National Enquirer with the headline “Patient Comes Back From The Dead”. The article included the name of the ICU attending physician who subsequently had to change his home phone to a new, unlisted number because of all the people calling him wanting him to bring back their own relatives from the dead.

What had happened was that the patient had breath-stacking due to the severity of his COPD and eventually breath-stacked enough that the high pressure inside of his chest prevented any blood return to the right ventricle and he became asystolic. Once he was taken off of the ventilator, the blood started to return into the chest and his heart started beating again. Although not well-recognized at the time, we now know this to be an important reversible cause of asystole during cardiopulmonary resuscitation and will usually give a trial of stopping ambu-bag ventilation in patients with asystole during CPR.

In this case, the patient did go on to die in the ICU a few days after his “miraculous” recovery from death. But ever since, I always wait a few minutes and re-check the pulse and respirations in a patient that I am pronouncing dead, even if I don’t have a sports page to read.

October 16, 2016


Inpatient Practice

Reducing COPD Readmissions

On average, about 1 out of 5 patients admitted to the hospital with COPD in the U.S. get readmitted within 30 days. There is a wealth of medical literature analyzing COPD readmissions. For example, we know that patients at risk for readmission include:

  1. Patients without physician follow-up within 30 days of discharge
  2. African Americans
  3. Older patients
  4. Divorced/widowed patients
  5. Those with longer initial hospital stays
  6. Patients in nursing homes
  7. Patients with anemia (hemoglobin < 8)
  8. Patients with renal failure
  9. Patients receiving cancer chemotherapy
  10. Patients with low health literacy
  11. Patients on Medicaid
  12. Patients taking > 5 different medications

There are a lot of reasons why they get readmitted. Some of the reasons include:

  1. Insufficient outpatient follow up
  2. Medication errors
  3. Poor transfer of information to primary care providers
  4. Inability to pay for medications
  5. Inadequate transportation
  6. Incorrect inhaler technique
  7. Lack of a “rapid action plan”

Interestingly, only 28% of patients with an initial hospitalization for COPD are readmitted with COPD. More than half of those readmitted are for non-respiratory conditions such as heart failure, arrhythmias, intestinal infection, sepsis, and electrolyte disturbances. Also, readmissions occur pretty quickly with 50% of readmissions occurring in the first 2 weeks after discharge. So what can we do to reduce COPD readmissions? Successful strategies employ interventions both during the hospitalization and after hospitalization.

During hospitalization:

  • Screen patients for readmission risk factors
  • Communicate with primary care providers
  • “Teach back” to educate patient (respiratory therapists can be valuable)
  • Use interdisciplinary clinical teams
  • Start on maintenance long-acting inhalers
  • Start on roflumilast (if indicated)
  • Discuss end-of-life wishes
  • Comprehensive discharge planning
  • Ensure patients can get and manage their medications
  • Schedule an outpatient follow up visit
  • Make sure patients have a nebulizer

After discharge:

  • Promote self-management (emergency action plans)
  • Follow-up phone calls
  • Develop and use transition clinics
  • Home visits for patients with transportation barriers
  • Electronic medical record management of information
  • Establish community networks
  • Use telemedicine when appropriate
  • Arrange spirometry testing
  • Enroll in pulmonary rehab
  • Smoking cessation

We started a nurse practitioner-run pulmonary transition clinic at our hospital and were able to reduce COPD readmissions to 12.5%. However, we did see a sizable no-show rate and those patients who failed to show had a very high (27%) readmission rate. The specific actions that occur in our transition clinic include:

  • Clinic appointment within 5 days of discharge
  • Assess response to treatment
  • Follow up lab and radiology tests
  • Arrange pulmonary function tests
  • Medication reconciliation
  • Refer to indigent patient medication assistance programs
  • Arrange pulmonary rehabilitation
  • Smoking cessation
  • Insure correct use of inhalers

Readmissions cost all of us in the long run since they increase insurance/Medicare/Medicaid costs. Care coordination and education are key elements of any readmission reduction strategy. Respiratory therapists are often in the best position to champion patient education in the hospital. Ultimately, it requires a culture change in our approach to COPD – culture always trumps hospital policy.

October 14, 2016

Inpatient Practice Outpatient Practice

You Can’t Get The Flu From A Flu Shot

vaccinationIt is flu shot season and my goal each year is to give more influenza vaccines in my clinic than any of the other pulmonologists. So, I offer it to all of my patients and continue to be amazed at how many of them decline because “Every time I get a flu shot, I end up getting the flu”. There is no live virus in a flu shot so you are just as likely to get the flu from a flu shot as you are likely to get pregnant by taking a birth control pill.

So why are patients so sure that they’ll get an infection from the flu shot. There are two main reasons. First, they may have had some muscle pain at the injection site or even some mild myalgia after a previous injection – this is a reaction to the vaccine and not an infection. If anything, it means that the vaccine is working because your immune system is mounting a response to it.

The other reason patients think that they get the flu from a flu shot is from superstition. The average American gets 2-4 upper respiratory infections (“colds”) per year. Lets just say it averages out to 3 colds per year. That works out to 1 cold every 17 weeks. In other words, statistically, 1 out of 17 patients will get a cold within a week of getting a flu shot purely by chance. Because they associate that cold with the flu shot, they incorrectly deduce that the vaccine caused the cold (which they equate to the flu). By the same argument, 1 out of 17 patients will get a cold within a week of Easter but you don’t hear patients telling you that they got the flu from the Easter bunny.

As it happens, if it wasn’t for influenza, I never would have been born. My grandmother’s first husband was one of the 21 million people who died of the “Spanish” influenza epidemic of 1918-1919. She then remarried to my grandfather so if her first husband hadn’t died of the flu, I wouldn’t be writing this post now. In the United States, about 23,000 people die of influenza each year; some years more and some years fewer, depending on the specific strains that go around that year.

It is particularly important for all healthcare workers to get vaccinated so that they don’t become a vector to transmit influenza to vulnerable patients. A few years ago, I admitted one of my patients with pulmonary fibrosis to the hospital with worsened shortness of breath. On admission, I did a bronchoscopy and sent PCR testing for influenza – it was negative. We determined that he was in heart failure and he improved over the days with diuresis. He lived alone and had no relatives so during his hospital stay, he had no visitors. After about a week, he became suddenly worse with hypoxemia and high fever. I repeated the bronchoscopy and this time, his influenza PCR was positive for influenza A. Based on the incubation period, he had to have acquired his influenza in the hospital. Since he didn’t have any visitors, he had to have acquired it from one of the doctors, nurses, or therapists. He never made it out of the hospital and died of his influenza in our ICU.

So, I’m pretty passionate about getting everyone who works in the hospital vaccinated for influenza each year. I don’t care so much whether they get influenza but I don’t want them transmitting it to a patient who would be more likely to die from it.

October 12, 2016

Inpatient Practice

A Consult Is Not A Sign Of Weakness

stop-consults-signTwo days ago I got an urgent email from one of our case managers asking if I could see a patient with asthma in the office ASAP. She was in the hospital with her third asthma exacerbation in 2 months and the case manager was trying to keep her from being admitted yet again. Although my practice is primarily interstitial lung diseases, I do try to help out with other pulmonary diseases when I can. I pulled her up on our electronic medical record and found that she had never had an inpatient pulmonary consult with any of her previous asthma admissions.

So, why in the world would a patient with a disease that is this difficult NOT have a consult by a specialist? I think it is a reflection of how residents are often trained. Going back to my own internal medicine residency, the mantra of the senior residents was that “A consult is a sign of weakness”, meaning that if you ordered a consult to an internal medicine specialist, it meant that you weren’t smart enough to handle that problem yourself. It wasn’t just my own specialty of internal medicine – a senior surgery resident told me that he didn’t get medical specialty consults because “A surgeon can do anything an internist can do plus we can operate”.

Over the years, those attitudes have become embedded in the culture of American medicine. What we forget is that the practice of medicine is a skill and like any skill, if you want to be good, the practice of medicine takes practice. Let me give you the analogy I use with my medical students. If you want to learn to ski, you can’t just read a bunch of books about skiing. You can’t just watch a bunch of videos of experienced skiers. And you can’t just strap on skis, go to the top of the slope and then try to get to the bottom over and over again. Truly learning a skill takes all three: didactic education, observation of skilled practitioners, and practice on your own.

In some residencies, the didactic education will be awesome, for example, many academic medical centers. In some residencies, there will be extraordinarily experienced clinicians that you will observe, for example, many community hospitals. In some residencies, the interns and residents are often on their own and get a lot of “sink or swim” experience taking care of patients independently, for example, some VA hospitals. Each resident needs a different optimal mix of didactics, observation, and practice to reach his or her potential. But all residents need each of them in some combination.

The thing that sets a specialist apart is that he or she has had a lot more practice with a specific group of diseases. And that practice can translate into more nuanced care, particularly for those difficult-to-treat cases. Furthermore, the specialist that sees the patient in the hospital is often the one who will be seeing that patient in the outpatient clinic and that translates into better continuity of care.

The literature confirms that inpatient consultation improves outcomes in difficult cases. A study presented at the Society of Hospital Medicine showed that inpatient cardiology consultation reduced the 30-day readmission rate for heart failure from 26% to 15%. A study of inpatient geriatrics consults showed a reduction in 6 & 8 month mortality rates. A study of inpatient palliative medicine consults showed a reduction in readmissions from 15% to 10%.

As a specialist who sees both inpatient and outpatient consultation, I don’t believe that there is any question too small or medical problem too minor and so I will never criticize another physician for requesting an inpatient consult. However, I will criticize a physician for not getting an inpatient consult when they should have. A patient with a medical illness who is being repeatedly readmitted is more complex and takes a lot more of the consultant’s time than a patient with the same disease but more minor symptoms who never gets admitted to the hospital. Insurance companies recognize that, for example, a level III inpatient new/consult visit has 3.86 work RVUs whereas a level V outpatient new/consult visit has 3.17 work RVUs. The implication is that it takes more time and more complexity to take care of that problem if it is bad enough to result in a hospitalization than if the patient is in an ambulatory office setting. So, I don’t want to see that really sick patient in the office, I want to see them in the hospital where I will have more time to do the evaluation and more diagnostic and therapeutic resources immediately available.

An inpatient who is challenging enough that they need to be seen by a specialist immediately after discharge is challenging enough that they should be seen by that specialist while they are still in the hospital. Because a consult is not a sign of weakness.

October 8, 2016

Outpatient Practice

340B Programs

pills-2Ohio State is about to expand its 340B program to include a free-standing pharmacy and the outpatient infusion centers. It gave me a chance to brush up on what a 340B program is. The 340B program was created by the federal government in 1992 as a way to provide discounted outpatient drug pricing to healthcare institutions that care for the poor. There are 6 categories of hospitals that are eligible that largely have in common that they are tax-payer funded to care for low-income and uninsured patients:

  1. Disproportionate share hospitals
  2. Children’s hospitals
  3. Cancer hospitals exempt from the prospective payment system
  4. Sole community hospitals
  5. Rural referral centers
  6. Critical access hospitals

In addition, hospitals have to either be state/government-owned, be a private not-for-profit hospital that has been granted governmental powers, or be contracted with the government to provide care to low income patients. In addition to hospitals, there are certain outpatient clinics that are also eligible to participate. As of 2014, there were 2,140 hospitals in the program, 90% of which are either critical access hospitals or disproportionate share hospitals.

The way the program works is that the Health Resources and Services Administration (HRSA) sets the maximum amount that drug companies can charge for outpatient medications – on average this is about a 22.5% discount. Medicare part B covers some outpatient medications (eg, cancer chemotherapy and rheumatoid arthritis infusion drugs); however, the hospitals participating in the 340B programs get paid the same from Medicare part B for these drugs as they would if they were not in a 340B program. Therefore, the hospital stands to make money on 430B drugs. On the other hand, drug manufacturers have to sell the hospitals their drugs at the discounted 340B price and so they would like to limit 340B programs so that they can have a higher profit.  All told, 340B programs save about $4 billion per year in drug costs. There are about 7,000 different drugs in the 340B program.

Ideally, hospitals participating the 340B programs use the increased margin that they get from the 340B programs to help support the care of lower income patients. For example, using profits to pay for rheumatoid arthritis infusion drugs for patients who are low income and have no health insurance and otherwise would not be able to buy these rather expensive medications. The danger is that there is the potential for some hospitals to expand chemotherapy and infusion clinics since they can make a higher margin on the chemotherapy and infusion drugs. Overall, 340B sales account for about 2% of total drug sales in the United States so it is not an enormous amount but 340B pricing is disproportionately affecting high cost chemotherapy and rheumatology biologic medications.

I can see both sides of the argument for the 340B programs but at least for our hospital, it will allow us to treat patients who previously were too poor to be treated for conditions like rheumatoid arthritis and inflammatory bowel disease in the past.

October 5, 2016

Medical Education

13 People Years = 2 Dog Years = 1 Dean Year

The Ohio State University has new Dean of the College of Medicine, Dr. Craig Kent. We are very excited to have someone as esteemed to lead our college. But the occasion has caused me to look back on the medical school leaders at our university over my own career. I have had 8 deans or interim deans in the past 36 years since starting medical school. Each time there was a change, it seemed like it might be the end of the world as I knew it. But deans have a relatively short half-life as it turns out.

The median length of tenure of a medical school dean is 6 years nationwide. There an average of 12 new deans appointed each year in the U.S.  A key question to ask when a new dean starts is how will he or she define success during their tenure at your medical school. Some deans define success in terms of longevity: whoever lasts the longest wins. Other deans define success in terms of specific objectives that they have when taking the job.

Department chairs have a slightly shorter tenure. Their average time on the job was 5.7 years for a full chair and 1.3 years for an interim chair. At Ohio State, we’ve definitely been the exception: in the 32 years since I started residency, I’ve only had 2 chairmen (and one interim for a brief few months). The first, Dr. Ernie Mazzaferri, was on the job for 15 years and the second, Dr. Mike Grever, is now going on 17 years.

To put that in comparison, the average duration of office for the 44 U.S. president is 5.1 years.

One of the reasons that deans and department chairs hold their jobs for a relatively short time is that we hire them based on their past scholarly performance but then we fire them based on their business performance. Large numbers of grants and publications can make a search committee swoon but if it turns out that the new dean or chair can’t read a profit and loss statement or has no concept of strategic planning in a competitive clinical market, then he or she is not going to keep their job very long.

One of the perpetual challenges that we have in academic medicine is that when you distill what we do, we basically have 3 missions: research, teaching, and clinical care. For tenure, research is king – historically, a medical faculty member could not get promoted simply by being the best teacher or the best clinician – they had to write about teaching and write about clinical medicine. But regardless, given their 3-part mission, colleges of medicine that are doing well with 1 of those 3 missions always look to hire a new dean or chair who has the promise of elevating one of the other 2 missions. If your college of medicine is doing great as a teaching institution, you don’t hire your next leader to elevate your already thriving educational mission, you hire the leader who you think can elevate your lagging research or clinical mission. If the college of medicine is not careful, this can result in perpetually changing sense of institutional self-identity and priorities.

I’ve heard some chairs lament that their job is no longer fun because of a perceived shift from the job being one of promoting scholarship to being one of running a business. And it is true that colleges of medicine and departments of medicine rely more and more on clinicians and the clinical income that they generate in order to fund the colleges’ operations. But I think that as we have changed how we define success for a dean or department chair over the years that we have simply changed the job requirements for a dean or department chair.

October 4, 2016