UCSF mini-college provides hands-on experience with neuro exams

TAM/UCSF MEDICAL CENTER
Kevin Leary, MD, internal medicine faculty at Walter
Reed Army Medical Center in Washington, D.C.,
(left) practices ultrasound-guided procedural skills
on chicken carcasses during the University of
California San Francisco hospitalist mini-college.
Back to Basics
I By Larry Beresford
UCSF mini-college
ost primary care physicians will tell you it’s getting harder to maintain a traM
medical practice with a foot in both the outpatient and inpatient
provides hands-on realms.ditional
Caseload demands, inadequate reimbursement, and other professional
medical pressures are forcing primary care physicians to choose one setting
experience with and
or the other.
For those interested in exploring the field of hospital medicine, a unique,
neuro exams, three-day,
hands-on training course at the University of California San Francisco
Medical Center offered an opportunity to address some of the gaps in
procedure practice, (UCSF)
their inpatient clinical knowledge and skills, which either were not sufficiently
residency training or have atrophied from lack of practice.
and critical care coveredTheinhospitalist
“mini-college” allowed working hospitalists and prospective
to practice short neurological exams on real patients, use ultrasound
co-management hospitalists
to guide needle placements, interpret radiologic evidence, engage in diagnostic
CONTINUED ON PAGE
28
CAREER I
continued from page 1
Back to Basics
UCSF mini-college provides hands-on experience with neuro exams,
procedure practice, and critical care co-management I By Larry Beresford
reasoning exercises, and even conduct
online medical information searches, all
under the watchful eyes of UCSF faculty.
The course was limited to 27 participants
to maximize small group interactions. It
emphasized clinical practice needs identified in surveys of hospitalists and assessments by the faculty, led by Robert M.
Wachter, MD, professor and chief of the
division of hospital medicine at UCSF, a
former SHM president, and author of
the
blog
“Wachter’s
World”
(www.wachtersworld.com).
Participants in this intensive course
were a mix of working hospitalists in stable positions seeking to enhance their clinical practice, and physicians in various
stages of transition—in or out of hospitalist positions. More than half of the participants are in their first hospitalist job and
have worked in the field for less than two
years, according to attendee surveys. Twothirds say they are pretty satisfied and 24%
say they are very satisfied with their work,
according to the survey. Most say they love
the clinical aspects best, but others express
frustrations with caseload pressures and
ownership changes at their practices.
“For me, being a doctor always
meant being a primary care doctor, and I
find great joy working in both the inpatient and outpatient settings. But primary
care is becoming a losing proposition,”
says Ronald Distajo, MD, who has maintained a primary clinic practice for
Cambridge
Health
Alliance
in
Cambridge, Mass., for the past three
years—all the while moonlighting as a
hospitalist for the health system.
With student loans, long hours, and
relatively low pay in the outpatient setting,
Dr. Distajo plans to find full-time work as
a hospitalist. At the mini-college, he
received a phone call informing him the
outpatient clinic he practices in will close
by the end of the year. The UCSF course
seemed like a timely opportunity to bolster his inpatient management skills in
areas he believes he could benefit from a
refresher. “They’ve done a good job of
picking all of them,” Dr. Distajo says.
Another mini-college participant in
28 THE HOSPITALIST I DECEMBER 2008
transition, Madeleine Martindale, MD,
was looking to hear what “hospitalists in
other places are doing, to confirm and validate my own experience.” Dr. Martindale
recently left a hospitalist position in
Anchorage, Alaska, in part because of high
caseloads. “A lot of the topics presented
here will help me. I also wanted to learn
more about the range of responsibilities
expected in hospital medicine.”
With few work settings for hospitalists in Alaska, Dr. Martindale is planning
to become a traveling hospitalist in the
lower 48 states next year. She is hoping to
devote part of the year to practicing medicine in a high-altitude clinic, as she prepares to staff a clinic in Nepal operated by
the Himalayan Rescue Association. She
also plans to serve as the support physician—stationed mainly at base camp—for
a two-month Mount Everest climb.
“There are a lot of hospitalist services and
places to practice, if I’m willing to leave
Alaska,” she says. “I feel inspired to hear
hospitalists who love their jobs and are
interested in quality of care and safety.”
Student and Staff Member
Mini-college participants were issued temporary visitor privileges at UCSF, name
badges and lab coats. “So much of our
planning for this experience was about
getting [participants] into the hospital,
and to offer [them] a set of knowledge and
skills that may be new or taught in a new
way, which [they] can apply in [their own]
hospitals,” says Arpana R. Vidyarthi, MD,
a hospitalist at UCSF and mini-college cochair.
The first session, hosted by Gurpreet
Dhaliwal, MD, assistant professor of medicine, nocturnist, and recipient of a distinguished teaching award at UCSF, led participants through an exercise in clinical
reasoning, using a challenging case to exercise diagnostic skills. “When you leave
medical training, the assumption is that
you’re done, and you will get better and
better on the job somehow through experience,” Dr. Dhaliwal explained. However,
there is little in the literature addressing
how doctors actually get better and what
KAPO TAM/UCSF MEDICAL CENTER
Elizabeth Kwan, MD, (left) emergency physician at UCSF,
explains the nuances of ultrasound use to (l-r) Doron Israelsky,
MD, Southside Hospital in
Bayshore, N.Y.; Dhanalakshmi
Namasivayam, MD, hospitalist at
Meriter Hospital, Madison, Wis.;
and Maria Lewis, MD, a family
practitioner with Woodland Clinic
Medical Group, Davis, Calif.
PHOTOS BY
KAPO TAM
USCF MEDICAL CENTER
ABOVE LEFT: Dr. Namasivayam (left) and
Monico Banez, MD, a hospitalist at JacksonMadison County General Hospital in Jackson,
Tenn., discuss the challenges of practicing hospital medicine during the opening session.
❖
ABOVE RIGHT: UCSF respiratory therapist
Brian Daniel, RRT, reviews the “five Ps” of ventilator management for ICU patients.
❖
LEFT: Neurohospitalist J. Andrew Josephson,
MD, demonstrates what to look for in the brain
scan of an actual UCSF patient examined by
mini-college participants.
❖
BOTTOM LEFT: The 687-bed UCSF Medical
Center played host to 27 hospitalists during
the inaugural, three-day mini-college.
❖
BOTTOM RIGHT: Martine Sargent, MD,
emergency physician at San Francisco General
Hospital, (left) demonstrates how to use
ultrasound to identify the major blood vessels
in the neck of UCSF research assistant and
procedure volunteer Ian McAlpine (on the
gurnee) while Daniel Montes, MD, (center)
and Reina Rodriguez, MD, hospitalists from
Alta Bates Summit Medical Center in
Oakland, Calif., look on.
separates those who continue to improve
from those who plateau in their careers.
“What are the things doctors do to put
themselves in the upper 10% of diagnosticians? We know from other fields that
innate smartness rarely counts the most,
and that expertise is not something that
necessarily comes with experience.”
Dr. Dhaliwal recommends a program of “progressive reinvestment” in
diagnostics—a deliberate practice of challenging mental processes and learning
something new from every case. He also
suggests regularly seeking feedback from
peers, tracking down what happened to
patients treated and whether the discharge
diagnosis matched the hospitalist’s initial
assessment, and even practicing diagnostic
skills with sample cases like the New
England Journal of Medicine’s “Case
Records of the Massachusetts General
Hospital.”
Participants broke into small groups
to visit hospital wards with UCSF neurologists and intensivists, discuss actual cases
and practice their examination skills at the
bedside. H. Quinny Cheng, MD, a hospitalist and director of the UCSF’s medical
consultation and neurosurgery co-management services, walked them through
current research and controversies in the
pre-operative evaluation and management
of surgical patients, including recent data
on the use of anti-coagulants, beta blockers, deep vein thrombosis prophylaxis, and
drug-eluting coronary artery stents. UCSF
respiratory therapist Brian Daniel, RRT,
reviewed recent advances in ventilator
equipment, including the high-flow nasal
cannula.
S. Andrew Josephson, MD, a neurologist and director of the neuro-hospitalist
program at UCSF, says hospitalists gener-
THE HOSPITALIST I DECEMBER 2008 29
I BACK TO BASICS I
continued from page 29
SAN FRANCISCO
SOUVENIRS
Participants in the UCSF mini-college
received hands-on training and
nuggets of new information. Here are
some snippets of what they took
home from the three-day course:
The clinical reasoning session with
Dr. Dhaliwal was exceptional and
very unique. To spend time with
someone like that makes for a special experience. The preoperative
evaluation review of where the evidence stands with practice management decisions we often see in the
hospital was also helpful. From a
career standpoint, the knowledge covered here is very
applicable and very high yield.
—Kevin Leary, MD, internal medicine faculty,
Walter Reed Army Medical Center, Washington,
D.C.
The hands-on experience. Best was
he neurology—how you do a quick
neurologic exam on a hospitalized
patient? The procedures workshop
was also invaluable. Vascular
access is the procedure I do most
often, and if my hospital provides the
ultrasound monitor, I’ll start using it.
… I thought this course would be a
great refresher for me, four years out of residency. It
was not only a refresher, it’s an inspiration. We all want
to be the best at what we do.
—Leslie Copeland, MD, hospitalist, St. Tammany
Parish Hospital, Covington, La.
thought the ultrasound laboratory
was a lot of fun, which I’ll bring back
to my institution. I’m sort of old
school in how I place my lines, but
we do have two ultrasound
machines in the hospital, one on the
units and one in the emergency
department where they’re most likey to be used. It takes a little more
preparation and time to use ultrasound, but it clearly
benefits the patient.
— Marcus Zachary, MD, group leader, Cogent
Healthcare of California, St. Francis Memorial
Hospital, San Francisco
What I liked best were the small sessions. They were really informative.
Also, the pearls, such as neurological physical exams that don’t take 30
minutes, and the signs of upper
motor neuron disease. We often get
calls from the emergency department for patients who are reporting
weakness, asking if they should be
admitted. You are trained to deal with that, but this
was about how to do it in the real world.
—Reina Rodriguez, MD, hospitalist, Summit
Medical Center, Oakland, Calif.
At my hospital, we don’t have intensivists. So there’s not a lot of structure for critical care. I was interested
n seeing the studies about sepsis
and the emphasis on washing teeth
twice a day in the ICU. I was also
nterested in the discussion about
how not to just plateau in your
career. I’ve never been average my
whole life. I don t want to be an average physician,
and that’s why I came to this course.
—Moira Ogden, MD, hospitalist, Terrebonne
General Medical Center, Houma, La.
30 THE HOSPITALIST I DECEMBER 2008
Dr. Josephson explains how to conduct a fast but high-yield neurological exam on the run in the hospital setting. The threeday mini-college limited participation to 27 hospitalists in order to facilitate small-group learning.
Dr. Lewis (left) practices central venous access technique under the watchful eye of Dr. Kwan.
Ronald Distajo, MD, a physician with the Cambridge Health
Alliance in Cambridge, Mass., explores ultrasound applications.
ally do not have time for full neurological workups on their
patients. He suggests high-yield results can be derived from
quick assessments of patients’ language, gait, and visual
fields.
“I thought the neurology session was fantastic,” says
participant Marcus Zachary, MD, group leader for Cogent
Healthcare of California at St. Francis Memorial Hospital in
San Francisco. “I know across the country hospitalists are
being asked to bear a heavy load in this area, and we’re not
really prepared. Neurologists don’t want to come into the
hospital, and hospitalists increasingly are plugging the gap.”
Dr. Wachter convened a Department of Hospital
Medicine case conference discussion of a real patient. He
also led a simulated root cause analysis discussion of an
actual medical error, which occurred at UCSF when the
wrong patient was given an unnecessary cardiovascular
physiology procedure scheduled for a different patient
with a similar sounding name. Organized discussion of
medical errors, led by UCSF hospitalists, take place weekly at the medical center.
In a hands-on procedure workshop in the library,
Diane Sliwka, MD, who developed the hospitalist procedure service at UCSF, introduced the clinical benefits of
using ultrasound diagnostic imaging to guide routine central line placements, paracentesis, and thoracentesis in
hospitalized patients. She reviewed the basics of frequency, contrast, and sterile technique with ultrasound, and
the visual and spatial orientation necessary to interpret the
image on the screen. Participants used the equipment to
locate pockets of ascites in the abdomen of a UCSF
patient and frequent training volunteer known to have
pleural effusions. Participants also practiced needle insertion technique with actual hospital equipment on prepared chicken carcasses.
“Ultrasound does enhance the safety of bedside procedures. Ultrasound basics are learnable with practice and
give a new dimension of ‘sight’ to common bedside procedures,” Dr. Sliwka explained to the participants, 70% of
whom had not used ultrasound for bedside procedures.
“Where it’s available, you can learn to do it with a bit of
practice.”
Attendee Moira Ogden, MD, hospitalist at
Terrebonne General Medical Center in Houma, La., is
interested in bringing ultrasound-guided procedures into
her practice, although she fears access to the equipment
may not be easy to obtain. “I want to start using them; I
just need to know the cost,” she says.
Mini-college Motives
“We’ve been at it for a year with our new hospitalist program,” Dr. Ogden said. “There’s such a difference between
academic medicine and practice in the community. In my
hospital, it’s very busy, although we’ve really just scratched
the surface. It’s hard to keep up with the literature, and
when I saw the flyer for this course, it looked so in-depth—
almost like a re-introduction to hospital medicine.”
“Part of it was just plain curiosity—what is this going
to be about? What do they see as blind spots for hospitalists
in their day-to-day jobs?” asks Dr. Zachary, a six-year hospitalist, discussing his interest in attending the UCSF minicollege. “For the most part, my sense of the gaps has been
dead-on.”
Kevin Leary, MD, internal medicine faculty at Walter
Reed Army Medical Center in Washington, D.C., is not a
hospitalist, although his position with the teaching service is
similar in many ways. “My goal in coming here is to learn
more about the field of hospital medicine and to meet
physicians who are hospitalists,” Dr. Leary explains. “When
I leave my role in the military service, I would get a lot of
job satisfaction out of becoming a hospitalist.”
Charles Oppong, MD, a native of Ghana who now
lives in Los Angeles with his wife and infant daughter, is
waiting for his application for a California medical license
to be processed and currently works part-time as a hospitalist in Circleville, Ohio, and in LaCrosse, Wis. “Personally, I
enjoy caring for patients in the inpatient setting. I like the
challenges of keeping my medical skills current,” he says. “I
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heard about UCSF and its famous hospitalist program, and when they sent me a
flyer, I saw all of these topics to improve
my inpatient management skills.”
Organizers of the mini-college are
attempting to give participants an opportunity to re-experience “what it was like in
residency to participate in rounds with a
truly spectacular teacher. With the teaching resources we have here at UCSF, we
have the capacity to offer that kind of
experience,” Dr. Wachter says.
“Those of us who stay in academic
settings are constantly jazzed by our interactions with young people, who tend to
ask a lot of questions,” he adds. “For many
other hospitalists, they don’t have much
opportunity to step back and recapture
what brought them to the field in the first
place. That’s what I hoped to capture with
the mini-college. If we can do that, then
we’ve succeeded.” TH
Larry Beresford is a medical writer based in Oakland, Calif.
Julio Rivera, MD, of Ben Archer Health Center, Truth or Consequences, N.M., (left) and Dr.
Leary (center) practice paracentesis technique with the help of Nima Afshar, MD, an emergency physician and hospitalist practicing at San Francisco General Hospital and UCSF. A
patient volunteer with ascites was present to allow hospitalists to practice the use of ultrasound in locating the condition.
32 THE HOSPITALIST I DECEMBER 2008
SMALL GROUPS FOSTER
INTERACTIVE LEARNING
The rapid growth of the hospitalist field has been an exciting development for Dr. Wachter.
“But I’ve been struck by how the field’s educational needs are becoming more diverse.
There is a whole bunch of stuff [in routine practice] that we were trained poorly in,” he
said in a pre-mini-college interview.
The mini-college was established to respond to those emerging
needs, both as a statement of the areas in which hospitalists say they
want more help and as way for those in mid-career to get back to their
roots and re-experience the best aspects of residency training. The
sold-out course was limited to 27 participants; each paid $2,500 for
the opportunity to interact with the highly regarded UCSF faculty in a
number of disciplines.
The three-day course is promoted as a departure from typical
Dr. Wachter
medical education, including Dr. Wachter’s “Managing the
Hospitalized Patient” conference. Presented in San Francisco the past
12 years, the conference is co-sponsored by UCSF and SHM. “It’s one thing to hear the
experts’ PowerPoint-based stump speeches, and another to roll up your sleeves with hospitalist faculty and learn in a very personal way,” Dr. Wachter said. “What we know about
adult learning is that active is better than passive. We also know that something unique
happens in the clinical context of the hospital setting.”
Some topics not covered during the mini-college agenda included reading EKGs,
managing complex cardiac events, pain management, and palliative care. “Hospitalists
need to become more educated in the methodology of performance improvement, since
that is going to become part of how hospitals get reimbursed,” said Elizabeth Olberding,
MD, a mini-college participant and hospitalist with St. Luke’s Boise Medical Center in
Idaho. “Another thing not covered is the hospital care of pregnant patients. Whenever I
get a call from the obstetrician, my heart skips a beat.”
Where UCSF’s intensive approach to hospitalist training goes from here will
depend, in part, on feedback from the first group of participants. “We have talked about
how to scale up from this session and what will happen next,” says course co-chair Niraj
L. Sehgal, MD, a member of Dr. Wachter’s group and medical director of UCSF at Mount
Zion Hospital in San Francisco. “Do we target other organizations or academic medical
centers with whom to partner?”
Although much of the spade work is done, the logistical demands and enriched student-teacher ratios make it hard to recreate the hands-on course frequently. At least one
and possibly two mini-colleges are being planned at UCSF over the next year.—LB