Published in the June/July 2004 issue of Today’s Hospitalist
With a new class of residents about to finish training, and with many of them headed to careers as hospitalists, hospital medicine programs everywhere will soon face a very basic problem: how to help new physicians learn the ropes of working as hospitalists.
Cogent Healthcare, a hospitalist company with programs in 13 markets, long ago realized that its physicians, particularly those right out of training, needed a little help to make the transition to hospital medicine. That’s why it created a mentoring program in which senior physicians give advice on everything from career growth to working with specialists.
While mentoring programs are nothing new, Cogent’s initiative is unique because of the company’s size. With so many physicians, Cogent can draw upon a diverse pool of veteran hospitalists throughout the country to mentor its physicians. And because the company expects it physicians to follow certain processes, its mentoring program tends to be more formally structured than most.
Navneet Kathuria, MD, MPH, Cogent’s national medical director, says that the company first created its mentoring program when it began to grow and expand into markets outside its home base of Irvine, Calif. Hospital medicine was still a relatively new specialty at the time, and the company’s leaders wanted to make sure that its hospitalists understood not only the emerging field of hospital medicine, but Cogent’s systems.
Cogent, for example, uses experienced RNs and NPs as clinical care coordinators to assist with patient care. The company also developed “care guides” that help bring the latest clinical evidence about common conditions to the point of care.
Senior physicians visit Cogent’s hospitalist programs three to four times a year. Mentors typically spend two days working with a program so they have enough time to develop relationships with the program’s hospitalists, as well as other key hospital staff.
Making the transition
While Cogent’s mentors work with all physicians, many of their efforts naturally tend to focus on younger physicians. Dr. Kathuria explains that when physicians finish their training and take a job as a hospitalist, they often need a little help.
“When you come out of a training program,” Dr. Kathuria says, “you often feel like you need to take care of everything from A to Z while the patient is in the hospital. One of the key things that we try to impress on our physicians is to focus on the acute nature of the hospitalization.”
Along those lines, Cogent’s mentors urge hospitalists to view themselves as part of a team. “We tell them to use the primary care physician as a partner who can help inform you about the patient’s condition and whether something needs to be addressed,” Dr. Kathuria explains. “It might have already been addressed by the primary care doctor.”
“If something does need to be addressed, you can relay that information to the primary care physician,” he adds. “If there’s something unique that you think needs to happen, but it’s not critical or urgent, we have systems in place to communicate that to the primary care physician.”
“One of the key things we try to communicate is that hospitals are for acute problems, or chronic problems that have an acute exacerbation such as congestive heart failure,” he explains. “Hospitals are not the place to address chronic problems that have been going on for 10 years, problems that could be addressed just as well “and probably better “in an outpatient setting.”
For many physicians just out of training, working as part of a close-knit team can be something of an adjustment. “As a resident,” Dr. Kathuria says, “you take care of a patient, and oftentimes that patient will come and visit you in the clinic. So these folks don’t feel as comfortable providing care as part of a team.”
Working with specialists
Another issue that young hospitalists face “and Cogent’s mentors can address “is working with specialists like surgeons.
Take the example of the specialist who doesn’t respond to requests for consults. Cogent’s mentors, who tend to have 10 to 15 years of experience working as hospitalists, might focus on communication styles to get a better response from specialists.
“It’s very important how you interact on a personal level not just with patients, but with other hospital staff,” Dr. Kathuria says. “We might ask how the physician approached the specialist. Did you just ask the specialist to come and see the patient, or did you say, ‘I have a patient who has such and such an issue and I need your assistance?’ How you present an issue or problem can solve a lot of issues.”
When problems with specialists go beyond simple communication styles, Cogent’s mentors can get more involved. The company tracks its physicians’ interactions with specialists “how quickly consultants return calls, for example “and can use that information to help resolve problems.
Rather than have the hospitalist confront a specialist about their lack of response, mentors will often bring in the local program’s lead hospitalist. That physician can then meet with someone from the specialty group to resolve problems.
Help for mentors
To help mentors do their jobs, Cogent collects feedback from its hospitalists.
Before mentors actually visit a program, for example, hospitalists fill out an online survey that asks hospitalists to identify pressing issues. “Before the mentors go on-site,” Dr. Kathuria explains, “they already have some information about the practice.”
Cogent also recently began conducting more detailed surveys to find out just how well its mentors are doing. Dr. Kathuria presented some results from that process in a research abstract at the Society of Hospital Medicine’s annual meeting in New Orleans.
“The key message we heard was that a good mentor is someone who is doing the kind of work they’re doing,” Dr. Kathuria says. “A good mentor is someone who guides them in terms of improving themselves as clinical physicians and gives them some guidance about the future. You want a mentor who is nonjudgmental and someone who supports you, but who also helps you identify your weaknesses.”
In the survey, Cogent’s hospitalists also said they were concerned about privacy issues. “Mentees say they want a mentor whom they respect and can turn to when needed,” Dr. Kathuria adds, “but one who they will look forward to asking advice, who will see that the comments they make or the questions they ask stay private, so their job is not at stake.”
That plays into Cogent’s advantage of size. Because the company is so large, it can bring in mentors from other parts of the country. In some ways, Dr. Kathuria explains, working with someone who you don’t see every day can help lead to more open and candid discussions. “With someone internal, you already have a relationship, and that may not be as helpful,” he says.
Dr. Kathuria admits, however, that one downside of a national mentoring program is that the mentors visit in person only a few times a year. While hospitalists can e-mail or phone their mentors between visits, some of the surveyed physicians said that they would like a more regular presence. The lead hospitalist can also serve as a mentor in theses cases, Dr. Kathuria says.
In the future, Cogent plans to focus its mentors’ efforts to hone in on key issues. “The goal is to have educational sessions focus on specific topics,” Dr. Kathuria says. “One of the topics we’re concerned about is burnout, so we’re planning to educate our mentors and our lead physicians on burnout among their peers.”
Finally, Cogent is in the process of developing educational materials that will give protÃ©gÃ©s some hints on how to make the most of their mentor. “If you don’t identify your expectations of the mentoring process for hospitalists,” he explains, “they might not be in sync.”
Edward Doyle is Editor of Today’s Hospitalist.