The chief of service rotation: for each, their own.

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 rotationasbeingconceivedand implementedbyGeraldB.Healy, MD, the previous director of the service. The oldmodel of academicmedicine in the United States is slowly showing itself to be antiquated and has started to evolve, especially in large academicmedical centers that have found themselves in direct competition with for-profit organizations and private practices. The current milieu has resulted in a system inwhich 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 thequalityof carehasbeenelevated,other factors, such as the quality of care delivery, access to a clinician, integration of services, and managing liability, are becoming as important as thequalityof caredelivery.Thewell-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 onquality of care, education, and research (the commonly referred toacademic“triple threat”) butmust alsoprovide faster andpleasing 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-housepatients byadedicated support staff andphysicians. 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. TheDepartment ofOtolaryngology 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 fellowswere able to interact closely with a diverse group of well-reputed and experienced physicians rather than a single individual (which wouldhavebeen thehospitalist in charge of the inpatient service). Vice versa, the chief of service hospitalistmodel allows the physician the opportunity toworkwith everyone, including residents and fellows, on a close personal basis. It also allows the facultymembers tomaintain their individual outpatient practice. Other benefits of the system include enhanced interdepartmental relationships; it is important tonote 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 ingredientsmust 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 thereare 15 facultymembers, 13physicianassistants, and4 fellows on staff. For a facultymember 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 facultymembers. Thismodel 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 availabilityof a largenumberofmid-level clinicians, ofwhom2can 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 GraduateMedical Education–accredited programs in the country have a total of 2 fellows). Finally, 1 of themost 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 thosewhichareperformed in theoperating room).This extraordinarily complex consultation volume results in generationof a largenumber of relative valueunits 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 programcreatedby the leadership of the Department of Otolaryngology at BCH and works in their setting. Inourexperience, fora28-monthperiodbetween1996and 1998, ahospitalist otolaryngologypositionwascreatedatChildren’sNationalMedicalCenterbytheseniorauthorof thiscommentary (G.H.Z.). The objectives of the model were to facilitate more rapid evaluation of inpatient consultations for our hospital andservice for consultations froma largeneonatal serRelated article page 809 Chief of Service Rotation Original Investigation Research