Chief of Service Rotation
Original Investigation Research
Invited Commentary
The Chief of Service Rotation For Each, Their Own George H. Zalzal, MD; Rahul K. Shah, MD, MBA
We commend Adil and colleagues 1 for their analysis and description of a novel manner of balancing the competing demands of practicing in a large pediatric academic center in our current health care environment. As such, we believe it important to emphasize some parts of their study and perhaps add clarity to other aspects of their innovative model. Adil et al1 rightfully acknowledge the chief of service rotation as being conceived and implemented by Gerald B. Healy, MD, the previous director of the service. The old model of academic medicine in the United States is slowly showing itself to be antiquated and has started to evolve, especially in large academic medical centers that have found themselves in direct competition with for-profit organizations and private practices. The current milieu has Related article page 809 resulted in a system in which the quality of care is practically standardized across institutions—of course, there are outliers, but suffice it to say that American health care continues to work on and improve the quality of care delivery across institutions. As the quality of care has been elevated, other factors, such as the quality of care delivery, access to a clinician, integration of services, and managing liability, are becoming as important as the quality of care delivery. The well-known “value” equation of health care includes the variables of quality and cost, with some adding patient satisfaction. It is clear that the model of academic medicine in which we trained has disappeared. The modern academic practitioner not only has to focus on quality of care, education, and research (the commonly referred to academic “triple threat”) but must also provide faster and pleasing service in a very busy clinical and/or surgical environment (perhaps in the future referred to as the “quadruple threat”). How can a clinician be 4 things at once and manage these competing demands? The success of the hospitalist model2,3 has made private practitioners and academic centers realize that such a model is perhaps an important step in continuing to provide quality care to in-house patients by a dedicated support staff and physicians. The implementation by the Department of Otolaryngology at Boston Children’s Hospital (BCH) of a non–full-time hospitalist model, utilizing an existing faculty member as a “chief of service,” is innovative. The Department of Otolaryngology at BCH has subsequently implemented and perfected this model, the value of which has proved to be quite beneficial in their setting. The emphasis on “in their setting” is crucial and will be expounded on further herein. As stated by Adil et al,1 residents and fellows were able to interact closely with a diverse group of well-reputed and experienced physicians rather than a single individual (which jamaotolaryngology.com
would have been the hospitalist in charge of the inpatient service). Vice versa, the chief of service hospitalist model allows the physician the opportunity to work with everyone, including residents and fellows, on a close personal basis. It also allows the faculty members to maintain their individual outpatient practice. Other benefits of the system include enhanced interdepartmental relationships; it is important to note that for hospital administrators their innovative model had no negative effect on the income of the faculty or the budget of the division. As noted, the chief of service system works “in their setting.” For such a system to be successful and extrapolated to other programs, certain key ingredients must be in place. One of the most important variables is the size of the service; the chief of service system works in the setting of BCH because there are 15 faculty members, 13 physician assistants, and 4 fellows on staff. For a faculty member to be on inpatient service once every 15 weeks without disrupting his or her outpatient and regular schedule is different than for divisions that have, on average, 4 to 5 faculty members. This model cannot be extrapolated to most academic pediatric otolaryngology programs without modifications. Another key issue that is part of the success of chief of service rotation at BCH is the availability of a large number of mid-level clinicians, of whom 2 can be assigned to the inpatient service to assist the chief of service (this is in addition to the 1 dedicated fellow and 1 residents; most Accreditation Council for Graduate Medical Education–accredited programs in the country have a total of 2 fellows). Finally, 1 of the most important factors for a chief of service system to succeed is the presence of enough volume (ie, inpatient consultations). This is, of course, out of our control as clinicians, and these can be organic consultations (ie, “homegrown”) or transfers from other institutions. In the article by Adil et al,1 the number of daily consultations averaged 11.2 patients, with a subset of 63% involving a procedure (83% of those which are performed in the operating room). This extraordinarily complex consultation volume results in generation of a large number of relative value units and, more important, especially as far as pediatric otolaryngology is concerned, a large amount of billing that can subsidize the cost of such a system. Hence, the chief of service system was an outstanding, innovative program created by the leadership of the Department of Otolaryngology at BCH and works in their setting. In our experience, for a 28-month period between 1996 and 1998, a hospitalist otolaryngology position was created at Children’s National Medical Center by the senior author of this commentary (G.H.Z.). The objectives of the model were to facilitate more rapid evaluation of inpatient consultations for our hospital and service for consultations from a large neonatal ser-
JAMA Otolaryngology–Head & Neck Surgery September 2014 Volume 140, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
815
Research Original Investigation
Chief of Service Rotation
vice across the street (interestingly, very similar to BCH’s chief of service model). The position was a full-time hospitalist position, which was applauded by all concerned services but was not economically feasible after a 6-month period. It was then changed to a hybrid model in which the otolaryngologist hospitalist had the ability to schedule a few outpatient appointments every day so as not to lose his outpatient skills and, more important, to provide funds to subsidize the position. This model was eventually terminated as the division grew in size. Learning from our colleagues in pediatric surgery who have several emergencies every day, the ARTICLE INFORMATION Author Affiliations: Division of Otolaryngology, Children’s National Medical Center, George Washington University, Washington, DC (Zalzal); Department of Otolaryngology and Pediatrics, George Washington University, Washington, DC (Shah). Corresponding Author: George H. Zalzal, MD, Division of Otolaryngology, Children’s National
816
concept of a surgeon-of-the-day works well in their model, but not in our specialty. In summary, we applaud the BCH’s group in the creation of a chief of service position to be a highly innovative and successful model in their setting. This is not a model that neither can nor should be extrapolated to all academic settings; there are myriad factors that enable the success of the chief of service model, and similar innovation will be requisite to find the model that works for each specific academic medical center because they are all, unfortunately, unique. As such, we suggest that for each, their own.
Medical Center, George Washington University, 111 Michigan Ave NW, Third Floor, Ste 800, Washington, DC 20010 ([email protected]).
approach to pediatric otolaryngology inpatient care [published online July 31, 2014]. JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2014.1325.
Published Online: July 31, 2014. doi:10.1001/jamaoto.2014.1459.
2. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514-517.
Conflict of Interest Disclosures: None reported. REFERENCES 1. Adil E, Xiao R, McGill T, Rahbar R, Cunningham M. A chief of service rotation as an alternative
3. Russell MS, Eisele D, Murr A. The otolaryngology hospitalist: a novel practice paradigm. Laryngoscope. 2013;123(6):1394-1398.
JAMA Otolaryngology–Head & Neck Surgery September 2014 Volume 140, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
jamaotolaryngology.com
Original Investigation Research
Invited Commentary
The Chief of Service Rotation For Each, Their Own George H. Zalzal, MD; Rahul K. Shah, MD, MBA
We commend Adil and colleagues 1 for their analysis and description of a novel manner of balancing the competing demands of practicing in a large pediatric academic center in our current health care environment. As such, we believe it important to emphasize some parts of their study and perhaps add clarity to other aspects of their innovative model. Adil et al1 rightfully acknowledge the chief of service rotation as being conceived and implemented by Gerald B. Healy, MD, the previous director of the service. The old model of academic medicine in the United States is slowly showing itself to be antiquated and has started to evolve, especially in large academic medical centers that have found themselves in direct competition with for-profit organizations and private practices. The current milieu has Related article page 809 resulted in a system in which the quality of care is practically standardized across institutions—of course, there are outliers, but suffice it to say that American health care continues to work on and improve the quality of care delivery across institutions. As the quality of care has been elevated, other factors, such as the quality of care delivery, access to a clinician, integration of services, and managing liability, are becoming as important as the quality of care delivery. The well-known “value” equation of health care includes the variables of quality and cost, with some adding patient satisfaction. It is clear that the model of academic medicine in which we trained has disappeared. The modern academic practitioner not only has to focus on quality of care, education, and research (the commonly referred to academic “triple threat”) but must also provide faster and pleasing service in a very busy clinical and/or surgical environment (perhaps in the future referred to as the “quadruple threat”). How can a clinician be 4 things at once and manage these competing demands? The success of the hospitalist model2,3 has made private practitioners and academic centers realize that such a model is perhaps an important step in continuing to provide quality care to in-house patients by a dedicated support staff and physicians. The implementation by the Department of Otolaryngology at Boston Children’s Hospital (BCH) of a non–full-time hospitalist model, utilizing an existing faculty member as a “chief of service,” is innovative. The Department of Otolaryngology at BCH has subsequently implemented and perfected this model, the value of which has proved to be quite beneficial in their setting. The emphasis on “in their setting” is crucial and will be expounded on further herein. As stated by Adil et al,1 residents and fellows were able to interact closely with a diverse group of well-reputed and experienced physicians rather than a single individual (which jamaotolaryngology.com
would have been the hospitalist in charge of the inpatient service). Vice versa, the chief of service hospitalist model allows the physician the opportunity to work with everyone, including residents and fellows, on a close personal basis. It also allows the faculty members to maintain their individual outpatient practice. Other benefits of the system include enhanced interdepartmental relationships; it is important to note that for hospital administrators their innovative model had no negative effect on the income of the faculty or the budget of the division. As noted, the chief of service system works “in their setting.” For such a system to be successful and extrapolated to other programs, certain key ingredients must be in place. One of the most important variables is the size of the service; the chief of service system works in the setting of BCH because there are 15 faculty members, 13 physician assistants, and 4 fellows on staff. For a faculty member to be on inpatient service once every 15 weeks without disrupting his or her outpatient and regular schedule is different than for divisions that have, on average, 4 to 5 faculty members. This model cannot be extrapolated to most academic pediatric otolaryngology programs without modifications. Another key issue that is part of the success of chief of service rotation at BCH is the availability of a large number of mid-level clinicians, of whom 2 can be assigned to the inpatient service to assist the chief of service (this is in addition to the 1 dedicated fellow and 1 residents; most Accreditation Council for Graduate Medical Education–accredited programs in the country have a total of 2 fellows). Finally, 1 of the most important factors for a chief of service system to succeed is the presence of enough volume (ie, inpatient consultations). This is, of course, out of our control as clinicians, and these can be organic consultations (ie, “homegrown”) or transfers from other institutions. In the article by Adil et al,1 the number of daily consultations averaged 11.2 patients, with a subset of 63% involving a procedure (83% of those which are performed in the operating room). This extraordinarily complex consultation volume results in generation of a large number of relative value units and, more important, especially as far as pediatric otolaryngology is concerned, a large amount of billing that can subsidize the cost of such a system. Hence, the chief of service system was an outstanding, innovative program created by the leadership of the Department of Otolaryngology at BCH and works in their setting. In our experience, for a 28-month period between 1996 and 1998, a hospitalist otolaryngology position was created at Children’s National Medical Center by the senior author of this commentary (G.H.Z.). The objectives of the model were to facilitate more rapid evaluation of inpatient consultations for our hospital and service for consultations from a large neonatal ser-
JAMA Otolaryngology–Head & Neck Surgery September 2014 Volume 140, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
815
Research Original Investigation
Chief of Service Rotation
vice across the street (interestingly, very similar to BCH’s chief of service model). The position was a full-time hospitalist position, which was applauded by all concerned services but was not economically feasible after a 6-month period. It was then changed to a hybrid model in which the otolaryngologist hospitalist had the ability to schedule a few outpatient appointments every day so as not to lose his outpatient skills and, more important, to provide funds to subsidize the position. This model was eventually terminated as the division grew in size. Learning from our colleagues in pediatric surgery who have several emergencies every day, the ARTICLE INFORMATION Author Affiliations: Division of Otolaryngology, Children’s National Medical Center, George Washington University, Washington, DC (Zalzal); Department of Otolaryngology and Pediatrics, George Washington University, Washington, DC (Shah). Corresponding Author: George H. Zalzal, MD, Division of Otolaryngology, Children’s National
816
concept of a surgeon-of-the-day works well in their model, but not in our specialty. In summary, we applaud the BCH’s group in the creation of a chief of service position to be a highly innovative and successful model in their setting. This is not a model that neither can nor should be extrapolated to all academic settings; there are myriad factors that enable the success of the chief of service model, and similar innovation will be requisite to find the model that works for each specific academic medical center because they are all, unfortunately, unique. As such, we suggest that for each, their own.
Medical Center, George Washington University, 111 Michigan Ave NW, Third Floor, Ste 800, Washington, DC 20010 ([email protected]).
approach to pediatric otolaryngology inpatient care [published online July 31, 2014]. JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2014.1325.
Published Online: July 31, 2014. doi:10.1001/jamaoto.2014.1459.
2. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514-517.
Conflict of Interest Disclosures: None reported. REFERENCES 1. Adil E, Xiao R, McGill T, Rahbar R, Cunningham M. A chief of service rotation as an alternative
3. Russell MS, Eisele D, Murr A. The otolaryngology hospitalist: a novel practice paradigm. Laryngoscope. 2013;123(6):1394-1398.
JAMA Otolaryngology–Head & Neck Surgery September 2014 Volume 140, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
jamaotolaryngology.com
