A Tool for Benchmarking Hospital Medicine Practices

AN OFFICIAL PUBLICATION OF THE SOCIETY OF HOSPITAL MEDICINE
www.the-hospitalist.org
Volume 11 Number 1
January 2007
MUST
READS
• Are Hospital Ads
to Consumers
Ethical? p. 17
A STAKE IN THE SAND
Rights were not granted to include this image in
electronic media. Please refer to the printed publication.
• How Hospitals
Handle IT
Adoption p. 25
• A Hospitalist
Climbs Everest
p. 47
Breaking
NEWS
JHM ACCEPTED
FOR INDEXING
IN MEDLINE
The SHM Survey: A Tool for Benchmarking This Month in
SHM News p. 6
Hospital Medicine Practices By Gretchen Henkel
P
roductivity and compensation benchmarks can be useful when negotiating with
hospital administrators for increased reimbursements and support resources, when
recruiting hospitalists, and when conducting self-evaluations. For many of these
processes, hospitalists—and, indeed, hospital administrators—turn to the information contained in the voluminous SHM 2005-2006 Survey, “The Authoritative Source
on the State of the Hospital Medicine Movement.” (See “For More Information,” p. 32.)
With a response rate of 26%, the survey represents some 2,550 hospitalists across the nation, and its variables present a more comprehensive aerial view of hospital medicine than did
previous surveys. But on the ground and in the trenches, hospital medicine groups must be
careful to look at the survey’s metrics with a discerning eye.
When applying the survey metrics to one’s own practice, there can be benefits as well
CONTINUED ON PAGE
The Hospitalist
John Wiley & Sons
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Hoboken, NJ 07030
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• Register for the Leadership
Academy in February
• A Closer Look at
SHM’s Mission
• New Online Advocacy Tool
• Pharmacist-Hospitalist
Team Research Grant
Announced
• Chapter Reports
Society of Hospital Medicine
In December the Journal of Hospital Medicine
(JHM, the peer-reviewed sister publication of The
Hospitalist) was selected for indexing and inclusion in the National Library of Medicine’s MEDLINE (Medical Literature Analysis and Retrieval
System Online). MEDLINE is a bibliographic
database that contains 13 million references to
journal articles in medicine, nursing, dentistry,
veterinary medicine, healthcare systems, and
preclinical sciences. It’s the primary component of PubMed, part of the Entrez series of
databases provided by the Library’s National
Center for Biotechnology Information (NCBI).
“The Journal’s acceptance is a profound
recognition that hospital medicine has developed its own sphere of medical knowledge and
that hospitalists are making a significant impact on our modern healthcare delivery system,” says Larry Wellikson, MD, FACP, SHM
CEO.
JHM, an official SHM publication, debuted
in February 2006 and is the premier forum for
peer-reviewed research articles and evidencebased reviews in the specialty of hospital medicine. For more information about JHM, visit
www.interscience. wiley.com/ journal/jhm.
Contents
p. 35
Rights were
not granted
to include
this image in
electronic
media.
Please refer
to the printed
publication.
FEATURES
CLINICAL
A Pregnant Pause . . . . . . . . . .35
Deja Vu . . . . . . . . . . . . . . . . .38
The necessary evolution
of residency training
Old bugs wreak havoc with
patients once again
PATIENT CARE
Zapping Zingers . . . . . . . . . . .37
TRENDS
Hospital Advertising . . . . . . . .17
The inevitable tricky questions
that catch hospitalists off guard
Is it time for a closer look at
direct-to-consumer ads
TECHNOLOGY
Bias in Medicine . . . . . . . . . .33
The challenges of IT adoption
and how hospitals manage it
OPERATIONAL
Skilled Labor . . . . . . . . . . . . . .21
Nurse-midwife laborists add
value to hospital medicine
p. 21
Charts to Screens . . . . . . . . . .25
What you don’t see can
hurt you (and your patients)
COLUMNS &
DEPARTMENTS
SHM Point of View . . . . . . . . . 4
What’s Your Diagnosis? . . . . . . 5
Society Pages:
SHM News . . . . . . . . . . . . . . . 6
Public Policy . . . . . . . . . . . . 10
Legal Eagle . . . . . . . . . . . . . . 12
Career Development . . . . . . . . 14
✸ New Department!
p. 15
Images in Medicine . . . . . . . . 15
In the Literature . . . . . . . . . . 41
Practice Management . . . . . . 50
SHM Career
Center Classifieds . . . . . . . . . 55
Progress Notes . . . . . . . . . . . 82
THE HOSPITALIST
> JANUARY 2007
3
> SHM POINT OF VIEW
An Environmental Assessment for Hospital Medicine
Results of recent SHM surveys
❚❘ By Larry Wellikson, MD, FACP
n preparation for the SHM Board Strategic Planning Retreat in
November 2006, SHM performed a series of surveys to get a handle on the current and future world of hospital medicine. During
this investigational process, SHM contacted leaders in hospital medicine and throughout healthcare to get their input and perspectives.
In the final phases of understanding the hospital medicine landscape,
SHM launched a focused survey of SHM members in fall 2006 to
validate what we were hearing from our healthcare experts. Here are
some of our findings.
I
EXPECTATIONS OF HOSPITAL MEDICINE
While the list of these expectations can seem without end, our survey of hospitalists indicated the following expectations in order of
most importance as rated by the survey respondents.
• Provide high quality patient care: At the end
of the day even though hospitalists have many roles, the hallmark is
to be the best at the bedside that we can be;
• Effectively communicate
with other health professionals
While the list of expectations as well as patients and their
families: Hospitalists have crucial informacan seem without end, our
tion and insights. We have the responsibility to
survey of hospitalists
be experts in translating this knowledge so that
our patients and their families have an expert
indicated more than 10
partner in their healthcare. This translates into
key expectations.
efforts in health literacy and palliative care and
end-of-life care;
• Provide leadership in transitions and coordination of care: More and more often there are opportunities for fragmentation and voltage drops as patients move into
and out of the hospital. But even within the hospital, the frequent
handoffs by staff with shift changes or from ICU or ED to the rest
of the hospital create opportunities for errors and quality drop offs.
Hospitalists are expected to play a key role in minimizing these valleys in patient care and to set the standard for the institution. You
will be hearing more about this in future columns as SHM takes a
leadership role on a national level;
• Deliver efficient patient care with appropriate use of resources: This is the most studied aspect
of hospital medicine and one trait that is accepted now without much
question. Hospitalists are the first physician specialty expected to reduce resource consumption and improve the patient flow at their
hospital (i.e., throughput) while improving measurable quality;
• Help hospitals meet regulatory, quality,
and safety requirements: It seems that every day brings
a new mandate or measurement to our nation’s hospitals. Increasingly it falls to the hospitalist to work with the hospitals and their
staffs to meet these requirements. Hospitalists are becoming the de
facto chief quality officers (CQOs) in many hospitals;
• Collaborate with other health professionals to form and lead multidisciplinary
teams: Hospitalists know that we can’t meet this expectation
alone. The day of the individual as the all-knowing solo provider of
healthcare is going the way of the dinosaur. There is enough work to
go around, and the enlightened hospital is figuring out how to use all
the available man (and woman) power at its disposal. If we are to create the quality and efficiency we are expected to produce we will need
everyone pulling in the same direction;
• Broaden the scope of hospitalist practice through co-management of patients
with surgeons and other specialists: The fastest
growing aspect of hospital medicine is the role of hospitalists in comanagement with other physicians. The hospitalist has a role as an inhouse advisor to the emergency physicians, as an “extender” of the
overextended intensivists, as the perioperative manager of the medical problems of the surgical patients, and as the general physician
4
THE HOSPITALIST
> JANUARY 2007
for the acutely ill specialty patient. But this attempt to have hospitalists help everyone with everything creates opportunities for “scope
creep.” Hospitalists must be helpful to the rest of the medical staff,
but everyone needs to be careful to draw the lines of practice based
on competence and expertise and not simply availability and convenience; and
• Be a geriatric expert for the acutely ill
senior: Hospitalists are not geriatricians for the most part, but
the vast majority of the patients managed by hospitalists who do care
for adults are over 65. This vulnerable population has unique needs
and the penalties for miscommunication or mismanagement are severe and potentially lethal. Hospitalists will need to work with geriatricians, social workers, patients’ families, and other resources to
bring value to this key population of patients.
EDUCATION NICHE WORK
Hospitalists also are expected to play unique roles in healthcare education and the development of new knowledge. While this burden
may seem to fall disproportionately on academic hospitalists, many
community hospitalists also play a role here.
• Serve as a role model for residents and
medical students: Much of medical education in medical
school and residencies still occurs in the hospital. Hospitalists can
bring the enthusiasm of being on the cutting edge of the future of
healthcare to the next generation of physicians.
• Update medical education to address
the training of young hospitalists and other
health professionals: No one knows how large the gap
between what they were taught in med school and what they are expected to perform in real time in real life is as well as hospitalists do.
If hospitalists and the rest of the healthcare team are expected to improve quality performance (and measure it), mange patients efficiently, make the patient flow through the hospital go smoothly, and
communicate to all stakeholders through the transitions and coordination of care, then we had better change what is taught in our professional schools; and
• Increase medical knowledge in hospital
medicine through original research: Hospital
medicine is a unique discipline that hopes to rely on evidence-based
information. The Journal of Hospital Medicine provides a venue for
displaying new information that the cadre of young hospitalist researchers will provide in health systems and quality improvement and
patient safety studies.
By no means is this meant to be an exhaustive list, but rather a
“Top 10” (or 11) gleaned from our survey of hospitalists. This study
also examined the hospitalists’ view of the difficult issues facing hospitalists and the major barriers that hospitalists face in meeting these
extensive and lofty expectations. In future columns we will examine
these issues and barriers. In the meantime everyone should get back
to work. We still have much left to do. TH
Dr. Wellikson has been CEO of SHM since 2000.
It’s Easy to Contact The Hospitalist Editors!
Lisa Dionne, editor
E-mail: [email protected]
Phone: (201) 748-5880
Jamie Newman, MD, physician editor
E-mail: [email protected]
Volume 11 Number 1
January 2007
Editorial Staff
Lisa Dionne
Editorial Director
[email protected]
A Case of Pruritis Rash
❚❘ Jerry D. Brewer, MD, Kelly L. Brunner, MD, and Alina G. Bridges,
DO, Department of Dermatology, Mayo Clinic/Mayo Clinic College
of Medicine, Rochester, Minn.
HISTORY OF PRESENT ILLNESS
55-year-old male presented with a one and one-half week history of a sore
throat, shortness of breath on exertion, ankle edema, and arthralgias that began in
the ankles and subsequently spread to involve the elbows and wrists.
He had also developed a pruritic eruption involving the lower extremities, which
consisted of erythematous palpable purpuric lesions and patches with superficial and
central necrosis and ulceration, as well as a large 4-cm bulla of the right lateral ankle. (See
Figures 1 and 2, below.) Other skin findings included petechiae of the palms and multiple ulcerations of the hard palate. Laboratory evaluation demonstrated c-ANCA antibody positivity (1:512), a proteinase 3 antibody level of greater than 100 U/ml, and a
creatinine of 1.0mg/dl. TH
A
James Newman, MD, FACP
Physician Editor
[email protected]
Art Director: Liliana Estep, [email protected]
Copy Editor: Pamela Leis Higdon
Contributing Writers: Gretchen Henkel, Kari Hershey, Jane Jerrard, Rima
Jolivet, John Nelson, Patrick O’Rourke, David Oxman, Larry Rigsby, Andrea
Sattinger, Helena Summers, Erik Summers
WHAT’S YOUR
DIAGNOSIS?
Publishing Staff
Bill Thompson
Advertising Sales Manager
[email protected]
Vickie Thaw
VP and Publisher
[email protected]
Advertising Staff
Display Advertising
Frank Cox, Patrice Culligan
Pharmaceutical Media Inc.
30 East 33rd Street
New York, NY 10016
Phone: (212) 685-5010
Fax: (212) 685-6126
[email protected]
Classified Advertising
Robert Zwick
(212) 904-0377
[email protected]
The Society of Hospital Medicine
Phone: (800) 843-3360, (215) 351-2740
Fax: (215) 351-2536
Web site: www.HospitalMedicine.org
Mary Jo Gorman, MD, MBA, President
Russell L. Holman, MD, President-Elect
Steve Z. Pantilat, MD, FACP, Past President
Patrick Cawley, MD, Treasurer
Jack Percelay, MD, MPH, Secretary
Board of Directors
Alpesh N. Amin, MD, MBA, FACP
Bill Atchley, MD, FACP
Scott A. Flanders, MD, FACP
Stacy Walton Goldsholl, MD
Lisa Kettering, MD, FACP
Jeff Wiese, MD
Mitchell J. Wilson, MD
> Figure 1
Laurence Wellikson, MD, FACP, Chief Executive Officer
Todd Von Deak, Director of Membership and Marketing
How to Subscribe
Subscriptions are free for hospitalists, physician assistants, nurse
practitioners, residents, fellows, and other qualified healthcare providers.
To see if you qualify, please contact Anna Wesley via e-mail at [email protected] or by phone at (201) 748-5813. Paid subscriptions are
available to all others: individuals: $75; institutions: $150.
Postmaster: Send address changes to Circulation Manager,
The Hospitalist, John Wiley & Sons, 111 River Street, 8-01,
Hoboken, NJ 07030-5774.
> Figure 2
❚❘ What is the most appropriate treatment for this condition?
❍ a) Prednisone;
❍ b) Azathioprine;
❍ c) Cyclophosphamide;
❍ d) Prednisone combined with cyclophosphamide; or
❍ e) Vancomycin combined with rifampin
See p. 81 for the answer and a complete discussion.
The Hospitalist is published monthly by John Wiley & Sons on behalf of the Society of Hospital Medicine. Editorial, business, and production offices located at
111 River Street, Hoboken, NJ 07030; (201) 748-5813; (201) 748-6182 fax.
Printed in the United States by Cadmus Specialty Publications, Easton, Pa.
Copyright 2007 Society of Hospital Medicine, administered by John Wiley &
Sons. No part of this publication can be reproduced without the written permission of the publisher.
All materials published, including but not limited to original research, clinical
notes, editorials, reviews, reports, letters, and book reviews represent the opinions and views of the authors and do not reflect any official policy or medical
opinion of the institutions with which the authors are affiliated, the Society of
Hospital Medicine, or of the publisher unless this is clearly specified. Materials
published herein are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied
upon as recommending or promoting a specific method, diagnosis or treatment
by physicians for any particular patient. While the editors, society, and publisher believe that drug selections and dosages and the specifications and usage of
equipment and devices as set forth herein are in accord with current recommendations and practice at the time of publication, they accept no legal responsibility for any errors or omissions, and make no warranty, express or implied, with respect to material contained herein. Publication of an advertisement
or other discussions of products in this publication should not be construed as
an endorsement of the products or the manufacturers’ claims. Readers are encouraged to contact the manufacturers with any questions about the features
or limitations of the products mentioned.
Society of Hospital Medicine
THE HOSPITALIST
> JANUARY 2007
5
SOCIETY PAGES
News and information about
the Society of Hospital Medicine
Register Now for
February’s SHM
Leadership Academy
S
HM’s Level I Leadership Academy is back. If you were unable
to register for the sold-out September Academy, now is your
chance. This semi-annual course will be held during the week
of February 26–March 1, 2007, at the Gaylord Palms Resort and
Convention Center in Orlando, Fla. This course gives attendees
hands-on experience and a unique opportunity to learn from the best
in the field. All previous Level I academies have sold out weeks in advance, so reserve your spot today by visiting www.hospitalmedicine.org for more information.
Hospital Medicine Fast Facts
Profile of Academic Hospitalists
Academic Hospitalists
Work in the eastern United States
31%
Are pediatricians
40%
Are U.S. medical school graduates
95%
Have clinical full-time equivalency
.69%
See critical care patients
30%
Do surgical co-management
72%
Work on CPOE projects
68%
Include nurse practitioners per group
.82%
Concerned with work hours/life balance
27%
Concerned with hospitalist recruitment
19%
Concerned with professional respect
22%
Concerned with career sustainability
29%
Paid by salary (no incentives)
44%
Paid median compensation
$142,000
All Hospitalists
20%
11%
75%
.89%
75%
85%
54%
.43%
42%
35%
17%
15%
27%
$169,000
Academic hospitalists:
• Demographics: They are more likely to work in the eastern United States, to be pediatricians, and to have graduated from U.S. medical schools.
• Work: They spend less time doing clinical work, are less likely to see critical care patients
and do surgical co-management, are more likely to work on CPOE projects, and use nurse
practitioners to a greater degree.
• Concerns: They are more concerned with professional respect and career sustainability and
are less concerned with work hours/work-life balance and recruitment.
• Compensation: They are more likely to be paid by salary (no incentives) and receive less compensation.
Source: SHM’s 2005-2006 “Biannual State of the Hospital Medicine Movement” survey.
ASHP Foundation Launches New
Hospital Pharmacist-Hospitalist
Team Research Grant
Foundation seeks to encourage collaborative
studies of VTE prevention
enous thromboembolism (VTE) is a significant cause of morbidity and mortality in hospitals. It mostly affects patients with
primary medical conditions; those who have had surgery for gynecologic, orthopedic, urologic, and vascular conditions; and those receiving care in critical care settings.
The American Society of Health-System Pharmacists (ASHP)
Research and Education Foundation has created a new grant program sponsored by the Sanofi Aventis Group to support multidisciplinary research studies conducted by hospital pharmacists and hospitalists to prevent and treat VTE in hospitalized patients.
“Because the focus of a hospitalist is providing quality medical
care for hospitalized patients and the unique medical problems that
V
6
THE HOSPITALIST
> JANUARY 2007
they may face as a result of being hospitalized, the ASHP Foundation
felt it was important to offer hospital pharmacists an opportunity to
partner with this group of physicians,” says Daniel J. Cobaugh, PharmD, FAACT, DABAT, ASHP Foundation director of research. “We
wanted to focus the research grant on a major patient care issue that
can be effectively addressed through hospital pharmacist-hospitalist
collaborations. We believe this collaborative approach will have farreaching implications for improving patient care and patient safety.”
“The hospital of the future will be based on patient-centered
care, with measurable quality outcomes and delivered by teams of
health professionals,” explains Larry Wellikson, MD, FACP, SHM
CEO. “This collaborative process with hospital-based pharmacists
and hospitalists working together to improve VTE care is just the
kind of interdisciplinary teamwork that can serve as a beacon to lead
us to a better future.”
Applications should emphasize the following:
• Project objectives that address health services research related
to the prevention and treatment of VTE;
• Sound research methods that support the study objectives;
• Interdisciplinary collaboration between hospital pharmacists
and hospitalist physicians;
• The potential for findings to be replicated in other healthcare
facilities; and
• Prudent use of grant funds.
Potential areas of research focus include the use of appropriate
interventions to prevent VTE, optimization and monitoring of therapies used for VTE, ensuring continuity of care, provision of literacy-sensitive education to patients and caregivers, and health professional education.
Applications and detailed instructions for the Hospital Pharmacist-Hospitalist Collaboration: VTE Prevention and Treatment
Team Grant is available on the ASHP Foundation Web site at
www.ashpfoundation.org. The deadline for completed applications
is March 1.
SHM Launches New
Grassroots Advocacy Tool
rassroots involvement by SHM members is critical to our ability to influence health policy in Washington. That is why SHM
has launched a powerful new advocacy tool designed to help you
communicate quickly and effectively with your congressional representatives. Capwiz·XC, located in the “Advocacy” section of our Web
site, enables you to take action on any issue important to hospital
medicine by sending personalized communications to your elected
officials.
Advocacy doesn’t have to require a big time commitment. Communicating with your representatives in Congress now takes just a
few minutes at SHM’s Legislative Action Center. You can send an email whenever it is convenient for you, and our action alerts contain
sample text for you to use and personalize as desired. Physician payment reform, quality improvement, palliative care, and funding levels for the National Institutes of Health and the Agency for Healthcare Research and Quality are just a few of the many issues before
the 110th Congress. You can help influence the debate, improve patient care, and increase the visibility of hospitalists by making your
voice heard through Capwiz.
Capwiz has many other features that will help keep you informed and educated about the legislative process. These include an
interactive map to help you find your elected officials. Simply enter
your ZIP code or click on your state to find out who your elected officials are. From there, you can easily select one of the listed state or
congressional officials to see the full legislative biography page. Each
bio page includes direct links you can use to contact the legislator,
look up his or her key votes, and find staff contact information. You’ll
also find a plethora of information about each elected representative,
including:
• Office term;
• Co-sponsorship status;
• Contact information;
• Party affiliation;
• Political background;
• Committee(s); and
• PAC contributions.
Are you interested in looking up a piece of legislation recently mentioned in the news? Or do you want to monitor the various
G
CONTINUED ON PAGE
8
NEW YORK
SOCIETY PAGES News and information about the Society of Hospital Medicine > CONTINUED FROM PAGE 6
SHM CHAPTER REPORTS
New Jersey
The New Jersey Chapter of SHM held a meeting in September at the
Highlawn Pavilion in
West Orange, N.J. A
presentation titled “The
Role of Hospitalists and Hypertension in the Inpatient” was
given by Larry Bryd, MD. There were
23 attendees representing five hospital
medicine groups in attendance. The
meeting was sponsored by OrthoBiotech. The next New Jersey Chapter
meeting is scheduled for March or April
2007 and will take place in South Jersey.
Boston
The Boston chapter of SHM hosted
nearly 50 attendees at its October
meeting, held at Davio’s restaurant.
The featured speaker was Geno
Merli, MD, director of internal medicine at Jefferson Medical College in
Philadelphia. Dr. Merli spoke about
“Key Issues in VTE Prevention.”
At press time the Boston chapter’s next meeting was scheduled
for Dec. 7, 2006. The discussion
was expected to be “An Influenza
Pandemic: Is Your Hospitalist Program Ready?”
Pittsburgh
The Pittsburgh Chapter met in October
and included five participants from three
Pittsburgh-area hospitals. The speaker
for the event was Frank Michota, MD,
head, Section of Hospital Medicine,
Department of General Medicine, the
Cleveland Clinic Foundation. His presentation, “The Basics of Hospital
Throughput—A Case Study in Acute
Decompensated Heart Failure,” generated an excellent discussion on hospital throughput. An election for an acting president was conducted; Michael
Cratty, MD, PhD, will serve as acting
president. Additional elections will be
held as the chapter grows. The next
meeting will be held in January.
New York City
The New York City Chapter held an
event at in October at March Restaurant in Manhattan. Steven L. Cohn,
MD, FACP, chief, Division of General
Internal Medicine, director of medical
consultation service, and clinical professor of medicine at State University
of New York Downstate, gave an update on perioperative medicine. The
event was well attended. The evening
was sponsored by the Sanofi Aventis
Group.
GRASSROOTS TOOL FROM PAGE
6
bills that will affect issues important to
your practice? The “Legislative Action
Center” in the “Advocacy” section contains “Issues and Legislation” to help you
to stay on top of current legislation affecting healthcare. Keep track of any bill’s
name, summary, co-sponsor(s), and key
votes, while also monitoring SHM’s position on the legislation.
SHM is pleased to provide you with
the opportunity to become more familiar
with the political process and actively participate in influencing the policies that affect
hospitalists and their patients. Capwiz contains up-to-the-minute legislative data and
online tools to enable you to make a difference in the political process. Please visit our
Legislative Action Center today at www.hospitalmedicine.org. TH
❚❘ CHAPTER
UPDATES
ONLINE
For additional
information
on SHM
chapters visit
www.hospitalmedicine.org
and click on
“Chapters.”
8
THE HOSPITALIST
> JANUARY 2007
> SHM: BEHIND THE SCENES
❚❘ By Joe Miller
arlier this year, as I entered my second year in the
position of senior vice president of SHM, my boss,
Larry Wellikson, MD, asked me to take the lead in organizing a Senior Staff Planning Summit. The Summit
was held in late August 2006.
In preparing for the Summit, I sought a framework
that would help to guide a meaningful discussion among
the participants. At first I turned to the SHM Mission
Statement and Goals:
SHM mission statement: SHM is dedicated to
promoting the highest quality care for all hospitalized
patients. SHM is committed to promoting excellence in
the practice of hospital medicine through education, advocacy, and research.
SHM goals:
• To promote high-quality care for all hospitalized
patients;
• To promote education and research in hospital
medicine;
• To promote teamwork to achieve the best possible care for hospitalized patients;
• To advocate a career path that will attract and retain the highest quality hospitalists;
• To define the competencies, activities, and needs
of the hospitalist community; and
• To support, propose, and promote changes to the
E
A Closer Look at SHM’s Mission
healthcare system that lead to higher quality and
more efficient care for all hospitalized patients.
Although these were helpful, I did not feel they
gave sufficient guidance to a planning session that would
focus on specific programs, operational activities, and
initiatives. I decided to concentrate on the “needs” that
SHM attempts to address (see “Why SHM Exists,”
below) and realized that our society exists to serve two
masters: hospitalists as individuals and hospitalists as a
group (the hospital medicine specialty):
• Hospitalists: SHM exists to meet the needs of
individuals with regard to education, facts and
news, career satisfaction, networking with peers,
and the provision of resources and services.
• Hospital medicine specialty: Our specialty is
just 10 years old. SHM exists to help define the
specialty, track its growth and development, promote our accomplishments, develop leaders, advocate for public policy, encourage research and
scholarly pursuits, and encourage innovation. We
also seek to represent the diversity of hospital
medicine, recognizing the unique roles of both
community-based and academic hospitalists.
To address these needs, SHM has a first-rate staff
that delivers service, develops products and programs,
and manages projects. You have met the senior members of that group in this column (Geri Barnes, director
Why SHM Exists
The needs addressed by a professional society for hospitalists
Educate hospitalists
on clinical/quality
topics
Educate hospitalists on
management/operational/leadership topics
Enhance job satisfaction for hospitalists
Address the
needs of
hospitalists
Provide resources and
services to hospitalists
Communicate news/
ideas to hospitalists
Develop programs,
services, and policies that
recognize the diversity
of the hospital medicine
specialty
Promote value,
accomplishments,
and successes of
the hospital
medicine specialty
Promote change and
innovation in the
delivery of
inpatient care
Address the
needs of the
hospital medicine
specialty
Recognize the vital role of
community-based hospitalists in bedside care and
the hospital medicine
specialty
Recognize the vital role
of clinician-educators in
shaping future hospitalists
and the hospital medicine
specialty
Promote the research
and scholarly aspects of
the hospital medicine
specialty
Define the hospital
medicine specialty
Track the status of
the Hospital Medicine
Specialty
Create opportunities for
hospitalists to develop
relationships and
learn from peers
Advocate for public
policy that improves
inpatient care and the
hospital medicine
specialty
Develop leaders for
the hospital medicine
specialty
of education and Quality Initiatives; Steve Poitras, director of business operations; Scott Johnson, director of
information services; and Todd Von Deak, director of
membership and marketing). We also have a group of
consultants who provide exceptional expertise in specialty areas: Laura Allendorf (Advocacy and Public Policy), Tina Budnitz (Quality Initiatives), Kathleen Kerr
(Research), and Bob Lane (Information Systems).
There is another critical asset, however, that propels SHM forward with new ideas and hard work. We
have a highly motivated group of volunteer members
who work on our board of directors, committees, and
task forces. The broad range of that participation is also
depicted in the diagram.
This SHM team of staff and volunteers addresses
the needs of both individual hospitalists and the hospital medicine specialty as a group. The broad range of
products and initiatives offered by SHM are represented as the last element of the diagram.
This framework proved to be an extremely useful
tool for conducting our Senior Staff Planning Summit in
August. I hope it is also useful to you, our members, in
understanding the work we do on your behalf. If any of
you have questions, please contact me by phone: (215)
351-2465.
Miller is the senior vice president of SHM.
A response to the needs:
Products and Initiatives
• Annual Awards
• Antimicrobial Resistance
Resource Room
• Career Center
• Chapters
• Coding and Documentation
Precourse
• Collaboration with IHI and
Other Organizations
• Core Competencies
• Credentialing by ABIM
• Dashboard White Paper
• Discharge Planning Checklist
• DVT Awareness Campaign
• DVT Mentored Implementation
• e-Newsletter
• Geriatric Resource Room
• Glycemic Control Resource
Room
• Heart Failure Resource Room
• Journal of Hospital Medicine
• Leadership Academies
• Legislative Action Day
• Letters to Congress
• List Serves
• Mentoring
• Practice Management Precourse
• Productivity and Compensation
Survey
• Public Policy White Paper
• Quality Precourse
• Research Grants
• Resource Rooms
• RIV Competition
• SEPs Workshop
• Stroke Resource Room
• Survey Collaboration with AHA
• The Hospitalist
• Value Added White Paper
• VTE Resource Room
• Web site
A response to the needs:
Committees and Task Forces
• Annual Meeting Committee
• Awards Committee
• Benchmarks Committee
• Board of Directors
• Career Satisfaction Task Force
• Certification Task Force
• Curriculum Task Force
• Education Committee
• Ethics Committee
• Executive Committee of the
Board of Directors
• Executive Review Committee
• Family Practice Task Force
• Finance Committee of the
Board of Directors
• Hospital Quality and Patient
Safety Committee
• Heart Failure Award Task Force
• Leadership Committee
• Membership Committee
• Nominations Committee
• Non Physician Provider
Committee
• Palliative Care Task Force
• Pediatric Committee
• Pediatric Core Curriculum
Task Force
• Performance and Standards
Task Force
• Public Policy Committee
• Research Committee
• Resource Room Oversight
Committee
• Research, Innovation, and
Clinical Vignettes Committee
• Women in Hospital Medicine
• Young Physicians Committee TH
THE HOSPITALIST
> JANUARY 2007
9
A Look inside
> Healthcare
Transparency
PUBLIC POLICY
Policy issues critical
for hospitalists
An executive order calls for
making healthcare pricing and
quality indicators public
❚❘ By Jane Jerrard
ne of the many trends in healthcare today is a move toward
making specific quality and pricing information available to
the public.
“When you’re buying a car, you can easily compare quality, features, and prices to make an educated guess,” points out Eric Siegal,
MD, regional medical director, Cogent Healthcare, Madison, Wis.,
and chair of SHM’s Public Policy Committee. “In contrast, healthcare is completely opaque. People choose a doctor or a hospital—
sometimes for a surgery that’s life threatening—by word of mouth
or [based on] proximity. How do you make it possible to choose
based on quality of care and on price?”
Known as healthcare transparency, this trend is driven by multiple sources. “The [CMS] Hospital Compare initiative was a first step
in this, as were the Leapfrog initiative and the IHI [Institute for Health
Improvement] Collaborative,” says Dr. Siegal. “In fact, the government
is a little late to the game, but they’re quickly closing the gap.”
O
Slow Adoption of Electronic Records
Researchers at Massachusetts General Hospital (Boston)
and George Washington University (Washington, D.C.) unveiled the first comprehensive study on the use of electronic medical records (EMR). The conclusion: A mere 9%
of doctors currently use EMRs. Least likely to use the technology were physicians over age 55 and those in small private
practices with one to three doctors. The researchers estimate
that if the current rates of adoption continue, only half of U.S.
doctors will have systems in place by 2014—the deadline set
for widespread deployment by President Bush.
IOM Makes P4P Recommendations
for Medicare
The Institute of Medicine (IOM) recently released the report “Rewarding Provider Performance: Aligning Incentives
in Medicare,” which highlights the deficiencies of the current Medicare physician payment system and offers
thoughtful recommendations for implementing a pay-forperformance payment program within the Medicare program. The report, released in September 2006, is available
online at www.iom.edu/CMS/3809/19805/37232.aspx.
New Quality Measures for
Voluntary Reporting
More quality measures will be added to the Centers for
Medicare and Medicaid Services (CMS) Physician Voluntary Reporting Program (PVRP) in 2007, possibly including
more that will be relevant for hospitalists. CMS released a
list of 86 quality measures in the fall of 2006, stating that it
plans to select a subset as the 2007 PVRP measures. The
goal is to achieve an appropriate balance in measures to be
reported by different specialties. Most of the reporting
measures have been developed by medical associations
involved in the AMA’s Physician Consortium for Quality Improvement. SHM is participating in this process.—JJ
MANDATE FROM THE PRESIDENT
On August 22, 2006, President George W. Bush signed an executive
order requiring key federal agencies to collect information about the
quality and cost of the healthcare they provide and to share that data
with each another—and with beneficiaries. Agencies included in the
order are the Department of Health and Human Services (HHS),
the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the Office of Personnel Management (OPM).
The executive order directs these four agencies to work with the
private sector and other government agencies to develop programs
to measure quality of care. They were required by Jan. 1, 2007, to
identify practices that promote high quality care and to compile information on the prices they pay for common services available to
their members. Ultimately, the executive order calls for combining
that data in a comprehensive source on providers’ quality and prices;
this information will then be available to consumers.
President Bush has said that his order sends a message to health-
Excerpt from the Executive Order
In general … Each agency shall implement programs measuring the quality of services supplied by healthcare providers to the beneficiaries or enrollees of a federal healthcare program.
Such programs shall be based upon standards established by multi-stakeholder entities identified by the Secretary or by another agency subject to this order. Each agency shall develop
its quality measurements in collaboration with similar initiatives in the private and non-Federal public sectors.
Transparency of pricing information … Each agency shall make available
to the beneficiaries or enrollees of a federal healthcare program (and, at the option of the
agency, to the public) the prices that it, its health insurance issuers, or its health insurance
plans pay for procedures to providers in the healthcare program with which the agency, issuer,
or plan contracts. Each agency shall also, in collaboration with multi-stakeholder groups …
participate in the development of information regarding the overall costs of services for common episodes of care and the treatment of common chronic diseases.
Promoting Quality and Efficiency of Care. Each agency shall develop
and identify, for beneficiaries, enrollees, and providers, approaches that encourage and facilitate the provision and receipt of high-quality and efficient healthcare. Such approaches
may include pay-for-performance models of reimbursement consistent with current law. An
agency will satisfy the requirements of this subsection if it makes available to beneficiaries or
enrollees consumer-directed healthcare insurance products.
care providers that “in order to do business with the federal government, you’ve got to show us your prices.” The new requirements for
transparency will affect healthcare providers across the country because treating about one-quarter of Americans covered by health insurance entails “doing business with the federal government.” That
one-quarter includes Medicare beneficiaries, health insurance beneficiaries at the DoD and the VA, and federal employees. (The order
clearly states that the directive does not apply to state-administered
or -funded programs.)
HOUSE LEGISLATION: MAKE PRICES PUBLIC
Comprehensive pricing transparency may also be required on a state
level. On Sept. 13, 2006, Representative Michael Burgess (R-Texas)
introduced the Health Care Price Transparency Act of 2006 in the
House. This American Hospital Association (AHA)-supported legislation would require states to publicly report hospital charges for specific inpatient and outpatient services and would require insurers to
give patients, on request, an estimate of their expected out-of-pocket expenses.
The bill would also require the Agency for Healthcare Research
and Quality to study what type of healthcare price information consumers would find useful and how that information could be made
available in a timely, understandable form.
Thirty-two states already require hospitals to report pricing information, and six more are voluntarily doing so, but this legislation
would likely change the information that hospitals and other
providers are gathering and providing.
At press time, the legislation had been referred to the House
Subcommittee on Health.
HOW TRANSPARENCY WILL ROLL OUT
While the House legislation is in limbo, the executive order will have
an immediate effect on healthcare, starting this year. The quality
measures to be included in reporting will be developed from private
and government sources, including local providers, employers, and
health plans and insurers.
After the data are gathered and the information technology (IT)
infrastructure is set up, consumers will be able to access specific information on pricing and quality of services performed by doctors,
CONTINUED ON PAGE
10
THE HOSPITALIST
> JANUARY 2007
11
hospitals, and other healthcare providers. This information may be available through a
variety of sources, including insurance companies, employers, and Medicare-sponsored
Web sites.
One of the keys to success will be in the collaboration among the agencies involved.
“There’s a keen understanding among the major players that if everyone does their own
thing, we’ll have chaos,” says Dr. Siegal. “There has to be a significant degree of harmonization [among] physician measures, hospital measures, inpatient measures, and
outpatient measures.”
The good news is that hospitalists may be the
single best-prepared group of physicians
[for transparency] because we’re already doing it.
—Eric Siegal, MD
WHERE HOSPITALISTS FIT IN
Will healthcare transparency affect hospitalists? “It’s already impacting hospitalists,” says
Dr. Siegal. “Not on pricing, but on quality reporting. The good news is that hospitalists may be the single best-prepared group of physicians [for transparency] because we’re
already doing it. The question will be, as it becomes more pervasive, will it be done in
a way that is thoughtful, measured, and practical?”
Hospitals are likely to look to their hospitalists to ensure that their quality measurements are competitive. Dr. Siegal explains, “Hospitals looking to improve quality
will be most effective in getting results from the physicians whose financial incentives
are aligned with theirs.”
However, additional—or more public—quality indicators will not necessarily create a huge source of income for hospital medicine. “The low-hanging fruit won’t be the
patients that hospitalists see; it will be elective surgical cases,” predicts Dr. Siegal. “Those
are cleanly defined procedures, with bundled payments and predictable outcomes, where
a hospital can understand what happens and what’s included. Then they can say, ‘Why
do we charge 20% more for a total elective hip [surgery] than the hospital down the
road?’ ”
As transparency is rolled out in U.S. hospitals and healthcare systems, hospitalists will
look good. “Hospitalists already live in a quality reporting world, more so than other doctors,” says Dr. Siegal. TH
Jane Jerrard writes “Public Policy” for The Hospitalist.
THE HOSPITALIST
> JANUARY 2007
11
>
How to Stay Out
of Litigation
The top 10 ways to avoid a
malpractice suit
THE LEGAL EAGLE
Legal considerations
for hospital medicine
❚ By Patrick T. O’Rourke and Kari M. Hershey
e’ve defended physicians involved in lawsuits for more
than a decade. After representing dozens of physicians, nurses, and other healthcare professionals, we can say one thing
for certain: No one likes to get sued.
Good physicians struggle with the litigation process. Even when
their care has been absolutely appropriate, many doctors experience
great anxiety when they are accused of having negligently injured a
patient. Because they have trained so hard to gain their expertise,
many of our clients have found that a lawsuit strikes at them personally as well as professionally. At the end of the day, lawsuits cause
stress, take physicians away from their personal lives, and often lead
to serious financial and professional consequences.
Therefore, one of the questions that we most often receive is,
“How can a physician avoid lawsuits?”
W
TOP 10 WAYS TO STAY OUT OF LITIGATION
Good documentation: Often, in a lawsuit, plaintiffs’
attorneys will tell the jury the old adage, “If it’s not in the record,
it didn’t happen.” What everyone who has practiced medicine knows,
however, is that many things don’t make it to the chart. Physicians
don’t have the time to recount their conversations with patients verbatim. What we want to see in the chart are the following:
a) A description of the information provided by the patient that
factored into your diagnoses or treatment decisions;
b) A description of the physical findings or laboratory results
that factored into your diagnoses and treatment decisions;
c) A discussion of why you made a particular decision;
d) A discussion of the course of treatment you selected; and
e) A discussion of your anticipated follow-up.
Of these elements, we most often fail to see a discussion of
why you made a particular decision, and this is a crucial piece of the
record. As you know, physicians often have a broad range of treatment choices. Including information about why you selected a particular course of treatment—in light of the available data—makes
the record more understandable to the jury. A good chart lays out
more than just the physician’s actions. A good chart is so complete
that another physician could assume care for the patient tomorrow,
easily understanding both the course of treatment and why you
chose it.
1
Good communication: In his book Blink, Malcolm
Gladwell describes something defense lawyers have known for
many years: That the quality of the care does not determine whether
or not a physician gets sued. There are many instances in which a
physician who makes a mistake that causes an injury manages to
avoid litigation. There are also many instances in which a physician’s
care is appropriate, but the patient sues the physician after a recognized complication. What makes the difference?
More often than not, the determining factor in whether or not
a physician is sued is the patient’s perception of whether or not the
physician cared about her. In situations in which patients leave the
physician’s office believing that the physician listened carefully to
their complaints, spent the time to explain the course of treatment,
and genuinely cared about them as people, we don’t see as many lawsuits. If a physician explains why a complication occurred—not just
that it occurred—and appears empathetic to the patient, she has less
of a motivation to sue. Conversely, if the patient feels like the physician sees her as a commodity or didn’t take the time to understand her
complaints, the risk of litigation goes up.
One of the most important aspects of good communication is
adequate informed consent. Remember, informed consent is a dialogue—not a lecture. It requires physicians to discuss:
1) The substantial risks of the treatment;
2) The benefits of the treatment; and
2
12
THE HOSPITALIST
> JANUARY 2007
3) The alternatives to the treatment. Sometimes it’s difficult to
determine the substantial risks because a patient and a physician may
view the magnitude of a particular risk differently. Our rule of thumb
is that any risks associated with serious long-term sequelae, such as
permanent impairment, must be discussed, even if the probability of
the risk occurring is remote.
Good consultation: Many hospitalists do not have
long-term relationships with their patients. After a course of
hospital treatment, the patient will return to her regular physician. A
common breakdown occurs when the consultation between the hospitalist and the regular physician is inadequate.
On the front end, the hospitalist who receives a patient should
take the opportunity, if possible, to consult with the regular physician
about any ongoing course of treatment. Unfortunately, patients are
not always accurate medical historians and may not fully appreciate
their conditions or courses of treatment. Consulting with the regular physician helps to eliminate the possibility that an important aspect of the patient’s history or condition is overlooked.
On the back end, when the regular physician resumes care of
the patient, he should be able to reinforce the course of hospital care
and provide an additional layer of education about why the hospitalist
made certain treatment decisions. Of course, the regular physician
can serve in this role only if the hospitalist has taken the opportunity to inform the regular physician about the course of care.
3
Accurate representations: We are seeing more
cases in which physicians are being sued for alleged misrepresentations to patients.
For example, each of you has probably seen an ad in which a
Lasik provider advertises that the procedure is “20/20 or it’s free.” A
patient may be able to allege that this advertisement is a guarantee
that the procedure will result in 20/20 vision, but no medical provider
should guarantee a successful outcome. Each human body reacts differently to treatment, and there is no physician who has not seen an
unexpected outcome. Providing patients with unrealistic expectations
about their outcomes can lead to lawsuits, even if a physician has obtained a signed informed consent detailing the risks involved.
The situation is even worse when the physician misrepresents
his experience. We have defended cases in which physicians have told
patients that they had performed a procedure hundreds of times,
when that representation was not accurate. One of the greatest assets
available to physicians in litigation is their advanced training and professional experience, but that asset becomes worthless if a physician
gives the jury a reason to doubt his credibility. Once the jury believes
that a physician has misrepresented his experience, he loses the ability to credibly explain his treatment decisions.
4
HMO-directed medicine: It’s no secret that many
patients are dissatisfied with their managed care plans. In the
abstract, patients understand that rising healthcare costs have caused
insurers to limit care, but they are unwilling to view their own situations objectively. They believe that they are entitled to unlimited
medical resources. When the HMO tells patients “no,” they have a
tendency to transfer their frustrations to their physicians.
The coverage provided by the HMO is a contractual matter between the patient and the insurer. At the end of the day, the treating
physician does not control the patient’s eligibility for certain types of
care. What the treating physician cannot overlook, however, is that
the physician-patient relationship is a personal one that exists independently of the insurance relationship. The standards of professional
care require a physician to inform patients of all treatment options—
even if the physician believes that the HMO is unlikely to authorize
some of them. Ultimately, even if the cost of a treatment option
would be prohibitive, a physician must remember that the patient
has a right to be informed and to make her own decisions. Physicians
should also be receptive to advocating on a patient’s behalf about the
reasonableness or necessity of care.
5
Attend to the patient: Few things are harder to explain to a jury than a physician’s failure to personally attend to
a patient. The reality is that physicians may receive information over
the telephone or through an intermediary’s relay, and they often have
to use these means of communication. The risk is that a physician
will miss a detail that he would have seen if he had personally examined the patient.
Err on the side of caution. If your differential diagnosis includes
6
a potentially serious condition and your ability to rule out that condition might be influenced by physical findings, arrange to see the patient in person. If the situation does not allow for a face-to-face appointment, instruct the patient to seek medical care through an
emergency department or another provider.
Having been there, we can say that there is nothing more difficult for a physician than to have to admit, at deposition, “I wish I had
seen the patient personally.”
Adequate discharge instructions: Another reality of modern medical practice is that patients often leave the
hospital before their course of healing is complete. Patients may leave
the hospital shortly after surgery or while still affected by an illness.
Even when the treatment in the hospital has been appropriate, we
regularly see cases arising from the physician’s discharge instructions.
Patients allege that they did not receive enough information to allow
them to recognize the onset of potentially serious complications. To
prevent confusion, discharge instructions should address all areas of
potential concern, including pain, wound care, and signs of infection. The instructions should also include information regarding
whom to contact if questions arise and should instruct the patient to
return if she experiences a change in condition.
7
Be prepared to deal with misinformation:
Technology is wonderful. This morning, we typed the term “diabetes mellitus” into the Google search engine. It returned more than
7.3 million references. Within 30 seconds, we located the “final cure
for diabetes,” which was compounded from banana, bitter melon,
licorice extract, and cayenne pepper (among other things). While this
might cure diabetes, we have our doubts; however, we will leave the
debate to more scientific minds.
The problem is that sick people often become desperate people—
particularly when fighting diseases like cancer, AIDS, and Alzheimer’s.
They are likely to be vulnerable to misinformation and might be inclined to pursue courses of action that could actually harm them. Physicians must realize that they will regularly deal with patients who have
unrealistic expectations of the medical system. The only way physicians
can combat misinformation is by providing better information. Physicians need to be prepared to educate patients who have unsuccessfully
tried to educate themselves. Part of that education can be verbal, but
physicians should consider directing patients to reliable resources that
they can explore after leaving the hospital.
Patients are also bombarded by advertisements for prescription
medications, all of which are designed to persuade them to take an active role in requesting particular prescriptions. The problem is that
the physician is responsible for selecting an appropriate medication.
Physicians have to be able to explain why an advertised medication
may not be the best choice under the circumstances, no matter what
the TV commercial said.
8
Take responsibility: Everyone makes mistakes. No
physician is perfect, nor is it fair to expect perfection from those
who deal with the intricate machinery of the human body. A culture
of fear, however, has caused many physicians to believe that they
should not admit their mistakes. Our experience shows that recognizing and responding to mistakes is a far better course of action than
trying to pretend they didn’t exist.
Taking responsibility doesn’t mean admitting that you were negligent. It does mean acknowledging a complication when it occurs
and assisting the patient in minimizing the consequences. Sometimes
this will result in transferring the patient to another physician. At
other times, the physician may have to pay to correct the mistake.
Many medical malpractice insurance carriers now have programs targeted at promptly recognizing and reacting to unexpected outcomes.
These insurers realize that the best time to correct a bad situation is
within hours or days of its occurrence. Enlist the help of your insurer or hospital risk manager. If patients feel like their physicians are trying to minimize a situation, hoping mistakenly that it will go away,
it becomes much more difficult to avoid litigation.
9
in certain businesses or receiving kickbacks for medical care. But there
are many lawful forms of conduct that might cause a jury to question
why a physician chose a particular course of action.
Recent medical literature demonstrates that pharmaceutical
manufacturers direct 90% of an estimated $21 billion annual marketing budget at physicians, including the sponsorship of an estimated 300,000 annual education events. This amounts to approximately $13,000 per physician annually. Because of concerns that even
small inducements might have an unwanted effect upon physician
independence, the Stanford Medical Center recently announced a
new policy prohibiting physicians from accepting free drug samples
In situations in which patients leave the
physician’s office believing that the physician
listened carefully to their complaints, spent the
time to explain the course of treatment, and
genuinely cared about them as people,
we don’t see as many lawsuits.
or even small gifts from pharmaceutical sales representatives. Prominent newspapers have been running stories about the “free lunches”
physicians receive.
We’re not suggesting that physicians spurn pharmaceutical sales
representatives or that they avoid legal business opportunities. We
caution you, however, that smart plaintiffs’ attorneys are sensitive to
any indications that a physician has allowed his interests to influence
a patient’s treatment. Don’t put yourself in a position where a jury
could reasonably question whether or not you had your patient’s best
interests in mind.
Unfortunately, even if a physician observes all of these precautions, a patient still might file a lawsuit. If you sense a real potential
for litigation, contact your insurance company and provide notice of
a potential claim. This will help ensure that your insurance coverage
is available if a lawsuit is filed. It also allows the insurance company
to retain an attorney to assist you. The next time we write, we’ll provide our top tips for winning a lawsuit once it occurs. TH
Patrick O’Rourke is the managing associate university counsel for the University of Colorado’s litigation office. Kari M. Hershey, JD, practices health law in Colorado.
It’s Easy to Contact
The Hospitalist
Editors!
Lisa Dionne, editor E-mail:
[email protected]
Phone: (201) 748-5880
Jamie Newman, MD, physician
editor E-mail:
[email protected]
Don’t compromise your integrity: Physicians are professionals. Whether it’s fair or not, jurors hold
physicians to a higher standard of conduct. They expect more of doctors. They expect doctors to “do the right thing.” Consequently, jurors tend to punish physicians who place their personal interests
above their patients’ interests. Federal law already prohibits physicians from engaging in many forms of self-dealing, such as investing
10
THE HOSPITALIST
> JANUARY 2007
13
> Train the Teacher
A unique approach to improve your
teaching skills
❚❘ By Jane Jerrard
CAREER
DEVELOPMENT
f you work at a teaching institution, an important part of your career track may be teaching residents the work of hospitalists. “Within academia, there are two major tracks: research[er] and clinical educator,” says Sanjay Saint, MD, MPH, hospitalist and professor of
internal medicine at the Ann Arbor Veterans Affairs Medical Center
and the University of Michigan Medical School, Ann Arbor. “We’re promoted based on our clinical work and on education evaluations; it’s
helpful when we’re being reviewed if we’re seen as good teachers by our
students.”
How are your teaching skills? How much thought and effort do
you put into how you train your students? Do you take steps to improve your methods?
“Most of us have to work at being good teachers,” admits Dr. Saint.
“We watch excellent teachers and learn as we go.” What follows is the
advice of one excellent teacher.
I
Maximize your career
in hospital medicine
How to Fight
Skills Decline
Dr. Wiese recommends the
following to help students retain the skills and knowledge
they must pick up so quickly.
• Encourage students to
use the knowledge
frequently, or ensure
that they do so;
• Ask students to record
the data so that it’s accessible later;
• Teach methods and approaches, not facts; and
• Re-dose: cover the information again.
TEACHERS: CHAMPIONS FOR HOSPITAL MEDICINE
Jeffrey Wiese, MD, FACP, is an SHM board member and associate professor of medicine at Tulane University Health Sciences Center in New
Orleans, where he also serves as associate chairman of medicine, director of the Tulane Internal Medicine Residency Program, and associate
director of student programs, internal medicine. “From an [SHM]
board perspective, it’s been my agenda to better situate hospitalists as
teachers,” he says.
One reason he’s committed to boosting the number of hospitalistteachers is that Dr. Wiese believes the specialty is a perfect match for
imparting knowledge. “Hospitalists are better instructors primarily because of their greater accessibility for supervision,” he says. “Because of
the number of things they do and the consistent repetition with which
they do them, they also have a better familiarity with what students need
to know and how to do it.”
Another reason that hospitalists are excellent choices to train residents: “Hospitalists work at improving hospital systems and focus on
quality of care,” says Dr. Wiese. “What better group of people to teach
the systems of care and practice-based learning competencies?”
COACHING VERSUS TEACHING
The basis of Dr. Wiese’s theory of teaching is that you should think and
act as a coach—not a teacher. “A teacher is responsible for disseminating knowledge to his pupils; a coach is responsible for the performance
of his pupils,” explains Dr. Wiese. “With a coach, the success of the job
is contingent on the performance of the player—in this case, the student
or resident.”
The coaching theory goes deeper than that distinction. “Components of coaching include [the following]: You have to teach the necessary skill, but you have to motivate the person to want to do it right, create a vision of how they’re going to do it, anticipate and prepare them
for potential obstacles that might stand in the way of their performance,
and provide feedback and evaluation when they do it,” says Dr. Wiese.
“A football coach wouldn’t just tell you how to throw a ball. He would
teach you the skill and then watch you do it, while providing feedback
on your performance. He would tell you what the opposing team might
do to oppose your performance of that skill and prepare you to overcome that opposition. And then he would instill a motivation such that
you wanted to perform the skill well.”
Attributes of Best Physician Leaders
What makes a good leader? According to a survey of 110 physician leaders, physician educators, and medical students, the following traits and activities are seen as most important in effective physician leadership:
• Interpersonal and communication skills;
• Professional ethics and social responsibility;
• Influence used with peers to encourage the adoption of new approaches in medicine; and
• Administrative responsibility in a healthcare organization.
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THE HOSPITALIST
> JANUARY 2007
Dr. Saint, who is familiar with Dr. Wiese’s theory, says, “I like the
metaphor of coaching because a coach tries to make you better at what
you’re learning. A coach may use techniques that make you uncomfortable at the time, but if you look back after a couple of years, you’ll
be thankful that he pushed you.”
Another aspect of coaching that fits neatly into today’s clinical
learning is the team aspect. “Medicine is no longer an individual event,”
explains Dr. Wiese. “It’s a team activity, where the best patient care is
provided by a team of healthcare professionals from doctors to nurses to
physical therapists and others. Teaching the mentality of playing as part
of a team will help residents perform better in this environment as they
advance in their careers.”
TEACHING IN A “VACUM”
“I use the mnemonic VACUM [to describe coaching],” says Dr. Wiese.
VACUM stands for:
• Visualization: To pique interest in a topic or procedure, start
by asking students to visualize themselves using the skill. Repeatedly ask
them how they think they will put the skill to use.
“Get the person to picture herself with a patient,” urges Dr. Wiese.
This step both hooks learners at the beginning of a session and helps
teach them the skill.
• Anticipation: If you’re an experienced teacher and know your
students well, you know where they will struggle in the learning process.
“Think about the common pitfalls,” says Dr. Wiese. “Alert the student
to where she will get confused or make mistakes and spend time preparing the student for how she can avoid the pitfall. For example, if you’re
teaching them about putting in a central line, tell them, ‘You [might]
not think about the patient’s bleeding risk prior to procedure. Make
sure you know his INR [international normalized ratio] and platelet
count prior to starting the procedure.’ ”
• Content: “This is where most teachers go awry,” warns Dr.
Wiese. “Medical educators try to teach too much, and students try to
learn too much. Not every detail in a topic needs to be discussed. It’s far
better to sacrifice details to preserve time to ensure that students have
mastered the fundamental concepts of a disease or skill. They can
pick up the details later—focus on what they need to know.”
How do you know what to focus on? “The guidelines of what
students must learn during their internal medicine clerkship are voluminous,” says Dr. Wiese. “Find those that you think have utility in
your practice or utility to the students. The best strategy is to stick to
the fundamentals. With this strategy, they will walk away with the critical components that will empower them to pick up the details during
subsequent teaching sessions.”
• Utility: “This goes with content,” says Dr. Wiese. “Teach them
skills that they can utilize. Remember, utility varies from student to
student. A student heading into a future career in orthopedics will
find greater utility in learning about pre-operative care and management of atrial fibrillation than she will with a discourse on lupus.”
• Motivation: Motivation includes three subcategories. “Students or residents have to know that the coach is on their side,” says
Dr. Wiese. One way to do this is to learn their names—and use them
frequently. You should also use physical contact to show your support.
“Give a pat on the shoulder, or shake someone’s hand,” he advises. “If you’re in a classroom, move around the room. Show that
you’re accessible.” Finally, find people’s hooks—that is, what interests them.
So how do you know you’ve become a good teacher? “The ultimate goal of coaching is successful student performance—not awards
or approbation. The measure of your success is defined by seeing your
students months or even years later, doing right by a patient because of
what you taught them to do,” says Dr. Wiese. “Focus on that goal, and
everything else will fall into place.” TH
Jane Jerrard regularly writes “Career Development.”
Survey respondents also indicated that “coaching or mentoring from
an experienced leader” and “on-job experience (e.g., a management position)” are the most effective methods for developing physician leadership competencies.
Source: McKenna MA, Gartland MP, Pugno PA. Development of
physician leadership competencies: perceptions of physician leaders,
physician educators and medical students. J Health Adm Educ. 2004 Summer;21(3):343-354.
✸
NEW DEPARTMENT
>
A Case of Emphysematous Cystitis
❚ By Helena Summers, MD, and Erik Summers, MD
atient history: The patient is a 53-year-old woman, 70 days
status post-allogenic stem-cell transplantation for multiple
myeloma. She presents with fever, mental status changes, and
abdominal distension. Abdominal films are ordered.
P
SALIENT FINDINGS
The patient has air within the wall of the bladder (see Figure 1 below,
white arrow) and within the bladder lumen, diagnostic for emphysematous cystitis. On the lateral film the intravesicular air layers with
a gravity dependent air-fluid level (see Figure 2 below, black arrow).
The gas in the bladder wall is seen circumferentially. Because the lucency (air) remains in the dependent portions of the bladder, it must
be in the bladder wall itself.
PATIENT POPULATION AND DISEASE HISTORY
Fifty to 80% of patients with emphysematous cystitis are diabetic.
Other predisposing factors include immunosuppression, indwelling
catheters, neutropenic bladders, female gender, and bladder outlet
obstruction.
Most cases are caused by E. coli; less common pathogens are
Enterobacter aerogenes and Klebsiella pneumoniae.
On occasion, patients require cystectomy if unresponsive to
medical management alone. Emphysematous pyelonephritis (involvement of renal parenchymal, intrarenal collecting system, and/or
perinephric tissues), on the other hand, requires antibiotics along
with surgical intervention. Percutaneous catheter placement is indicated for gas in the collecting system or renal parenchyma. Further extension of the gas or abscess formation may require surgical resection
and/or total nephrectomy. Patients with emphysematous
pyelonephritis should have a CT scan to define the extent of involvement.
IMAGES IN HOSPITAL
MEDICINE
Radiologic images
for hospitalists
TAKE-HOME POINTS:
• Emphysematous cystitis is most common in diabetics;
• Pathogenesis is unclear at present;
• Emphysematous cystitis typically responds to IV antibiotics; and
• Emphysematous pyelonephritis requires systemic antibiotics and
surgical intervention (percutaneous catheterization, resection of involved tissue, or total nephrectomy). CT can characterize the extent
of tissue involvement and guide treatment. TH
Helena Summers is a radiology resident and Erik Summers is a hospitalist
at the Mayo Clinic College of Medicine, Rochester, Minn.
MANAGEMENT
Emphysematous infections are gas-forming infections of unknown
mechanism. Common symptoms of emphysematous cystitis include
abdominal pain, dysuria, and pneumaturia. Most patients with emphysematous cystitis (involvement of bladder only) respond well to
systemic antibiotics, good bladder drainage, and excellent glycemic
control.
Figure 1
REFERENCES
1. Stamm WE; Harrison’s Textbook of Internal Medicine, 16th ed; 2005, McGraw-Hill. Chapter
269.
2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;Mar 27;160(6):797-805.
3. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987 Jul;83(1):149-154.
Figure 2
It’s Easy to Contact The Hospitalist Editors!
Lisa Dionne, editor E-mail: [email protected]
Phone: (201) 748-5880
Jamie Newman, MD, physician editor
E-mail: [email protected]
THE HOSPITALIST
> JANUARY 2007
15
The Third Annual Update in Hospital Medicine presented by Mayo School of Continuing Medical Education was Nov. 8-11 in Tucson, Ariz. The course directors, Ellen Willis, MD, and Adriane Budavari, MD,
designed a course to cover not only general hospital
medicine, but also to apply research to clinical practice,
ethics, provider burnout, and medical history. The
course format provided the attendees with five hours of
early morning learning for four days, leaving afternoons
and evenings free to enjoy Tucson.
After years of continuing medical education
(CME) experience, including a stint as associate director of CME at Mayo Arizona from 1995 to 2001, Dr.
Willis held the first Mayo Hospital Medicine course in
Rochester, Minn., in 2004, with an attendance of 52. In
2005, the venue moved to Tucson, where attendance
reached 146, climbing to 161 in 2006. The course continues to improve; we know because of attendees’ reviews.
The 2006 course began with a review of medical
history followed by a discussion of disaster management
and the role of the hospitalist. The course continued
with review of therapeutic hypothermia in the ICU. The
next topics were advance directives, ischemic stroke
treatments, management of intracerebral hemorrhage,
and the proposed change in definition of transient ischemic attack. The first day concluded with common
ethical considerations during acute care.
Day two started with evidence-based medicine and
a research-based literature review of critical care management strategies. The course continued with presentations on dementia, seizure disorders in the elderly, blistering skin disorders, and wound management
principles. Palliative care was reviewed in an interactive
format. The day concluded with an array of “toxic syndromes” seen in acutely ill patients, and an evidencebased review supporting more aggressive diabetes mellitus management.
The third day the course started with an exploration
of alternative medicines. Then it covered avian influenza,
evidence-based recommendations for radiological workups in commonly seen inpatient problems, delirium, and
psychiatry. After that, there was an update on retrievable
IVC filters and one on hospital safety. The day concluded
with a panel discussion reviewing delirium case studies with
attendees’ participation.
The fourth day covered diagnostic approaches to primary aldosteronism, pheochromocytoma, and also abnormal liver tests. Pulmonary literature was reviewed including the relationship between acetaminophen and
respiratory disease. Discussions of common cardiac conditions and upper GI bleeding concluded the conference.
For those of you who need to store some Vitamin D
before the winter, or who would like a great review of hospital medicine, the next Update in Hospital Medicine will
be back in sunny Tucson Nov. 14-17, 2007.
THE 7TH ANNUAL SOUTHERN HOSPITAL
MEDICINE UPDATE
Ochsner Health System and the Emory University of
School of Medicine (Atlanta) hosted the 7th Annual
Southern Hospital Medicine Update Nov. 2-4 in New
Orleans. Both institutions combined their two successful hospital medicine conferences into one regional sym16
THE HOSPITALIST
> JANUARY 2007
posium after Hurricane Katrina last year.
Steve Deitelzweig, MD, FACP, and David Lee,
MD, MBA, FACP, from Ochsner partnered with Mark
Williams, MD, FACP, and Dan Dressler, MD, MsC,
from Emory. More than 200 healthcare professionals
participated in 20 hours of continuing medical education (CME) and the rebirth of New Orleans following
the devastation of Katrina last year. The update took
place in the heart of the revived French Quarter at the
Royal Sonesta Hotel.
The 2006 update started with a New Orleans
breakfast of beignets and café au lait. Russell Holman,
MD, SHM president-elect, gave a snapshot of the status of hospital medicine, followed by an inspirational
talk on leadership by Ochsner CEO Patrick Quinlan.
Cardiology topics were followed by an acute coronary syndrome update, discussion of optimizing management of renal artery stenosis, and updates on congestive heart failure management. Pulmonary and
critical care and perioperative management were the
topics of the afternoon. Robert Centor of University of
Alabama, Birmingham (UAB) worked through various
cases of sodium and acid-base problems. Mike Heisler
discussed the indications and various modes of mechanical ventilation. Amir Jaffer, MD, of the Cleveland
Clinic concluded the day with preoperative assessment
and postoperative complications. After a long day of
CME guests enjoyed a wine and cheese reception in the
hotel’s central courtyard, complete with live jazz music.
Then it was “laissez le bon temps rouler” on Bourbon
Street.
Day two commenced with vascular medicine and
use of clinical case-based teaching pertaining to stroke
and critical care. Steve Deitelzweig, MD, reviewed the
current advances in venous thromboembolism and
urged us to improve prophylaxis in the hospital. Dan
Dressler, MD, presented a systematic approach to
workup of syncope. The afternoon broke into two concurrent sessions.
The first session included endoscopic approaches
to the management of pancreas and biliary diseases,
acute gastrointestinal bleeding, and complex endocrine
and rheumatology cases. The concurrent session was
highlighted by the presentation by Mark Williams, MD,
editor of the Journal of Hospital Medicine, on how to optimize the discharge process and Dr. Renee Meadows’
review of strategies to improve safety in the hospital.
Then it was on to the French Quarter for the night.
The last half-day began with emerging infectious
diseases and hospital-acquired pneumonias. The Review
of Medical Literature was followed by a discussion by
Jeff Wiese, MD, (Tulane, New Orleans) concerning a
hypothetical case that involved the review of the most
current literature in 2006. The conference concluded
with the wrap-up and review of pearls by David Lee,
MD, and left participants with wonderful memories of
the atmosphere, foods, and music of New Orleans.
The response from the conference participants has
been so positive that the conference directors decided
to host the 2007 8th Annual Southern Hospital Medicine Update in New Orleans again and then move to
Atlanta in 2008. The conference will expand to include
pre-session procedure training, administrative courses
and abstract competition next year. TH
Background: The lovely Sonoran Desert, which was the
setting for Mayo’s 3rd Annual Update in Hospital Medicine
PHOTO MARK WILLIAMS, MD
THE MAYO 3RD ANNUAL UPDATE
IN HOSPITAL MEDICINE
The 7th Annual Southern Hospital Medicine
Update: (left to right) Steve Deitelzweig, MD,
Dan Dressler, MD, Kristin Harney, David Lee,
MD, Jeff Wiese, MD, and Val Cruschiel.
❚❘ By David Oxman, MD
B
y now Americans are accustomed to seeing advertisements for medical goods and services. The steady
supply of direct-to-consumer TV advertisements by
the pharmaceutical industry is probably the most
high-profile example. But while much has been
written about the negative effects of these advertisements, the impact of healthcare service advertising—by hospitals
as well as by individual physicians—receives comparatively little
attention and almost no debate.
While advertising by doctors and hospitals has been legal for
30 years, until recently, professional taboos discouraged the practice. Increasing economic pressures and changing cultural norms
have led, however, to the demise of these informal proscriptions,
and advertisements produced by hospitals and individual providers
are now common.
Yet arguments against healthcare-service advertising can be
made on both ethical and economic grounds. While advocates of
healthcare service advertising argue that the practice is harmless,
often educational, and economically essential, several recent studies of healthcare service advertising reveal that medical centers and
individual physicians often create advertisements that:
1. Manipulate patients’ ignorance and vulnerability; and
2. Stimulate demand for unproven or ineffective therapies.1-3
These advertising practices may lead patients not only to
make poor decisions about disease treatment or health maintenance, they may also encourage unnecessary risks or foster unrealistic expectations. Further, the relatively unrestrained manner in
which advertising for medical services is now practiced may increase the overall cost of healthcare.
CONTINUED ON PAGE
THE HOSPITALIST
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> JANUARY 2007
17
HOSPITAL ADVERTISING > CONTINUED FROM PAGE 17
HOSPITAL ADVERTISING AND THE
ETHICS OF PATIENT DECISION-MAKING
Those who support healthcare service advertising argue
that on the whole decisions regarding the purchase of
medical services are not significantly different than those
related to any other kind of purchase. In their opinion,
buying a car and buying a cholecystectomy are—in economic terms at least—not significantly different. They
argue that while consumers of healthcare—like their carpurchasing brethren—should be protected from false advertising they don’t warrant protection from more subtle
or manipulative appeals.
But if the “purchasing” of medical services is unique
among commercial transactions, then one could argue
that consumers of healthcare are ethically entitled to special treatment. Is medicine fundamentally different? It is
in both the milieu in which purchase decisions are made
and the special nature of
the patient-as-consumer
situation.
In the majority of
circumstances, the consumer of healthcare services can’t truly be informed
about what he or she is
buying. Assessing the efficacy and safety of medical
treatments requires time,
reflection, and often expertise that most patients
don’t have. Even if their
sponsors’ intentions are
honorable it is extremely
difficult for medical service advertisements to convey the complex risks-andbenefits
ratios
that
underlie intelligent medical
decision-making.
Complicating matters further, indicators of quality
in medicine are extremely
difficult to assess for the
healthcare professional—
let alone the layperson. As
one author has put it, “the
sheer complexity of medicine, and the quality
measures it has available,
virtually guarantees that
any statement about quality that can fit comfortably in a popular advertising format will be
deceptive … .”4
Admittedly, medicine isn’t the only area in
which purchasers of goods
or services have limited
knowledge about the
items they are buying.
Few people—including
this author—actually understand how computers
or cars work. Medicine,
however, is unique in that
purchasers of medical
services are not only relatively uninformed, but
they are also uniquely vulnerable and dependent.
More often than not, patients making decisions
about medical services are
under severe emotional
and/or physical duress.
They also depend on the
skills, goodwill, and conscientiousness of healthcare providers.
Yet while the vulnerable and dependent posi18
THE HOSPITALIST
> JANUARY 2007
tion of patients should encourage scrupulous avoidance
of manipulative or emotional messages in medical service
advertising, frequently just the opposite is true.1,5 In a
study of advertisements produced for academic medical
centers, Larson and colleagues found that more than 60%
of the advertisements directly appealed to patients’ emotions. Further, the same study found that medical centers
consistently promoted procedures or therapies with unproven benefits.
HOSPITAL ADVERTISING AND ITS EFFECT
ON THE COST OF HEALTHCARE SERVICES
Hospitals, medical centers, and individual physicians currently spend millions of dollars annually advertising themselves to the public.6 The question is, “What is the return
on all this money,” or (put another way) “Is all this spending worth it?” Certainly, the pervasive and increasing use
of advertising by healthcare institutions indicates that the
advertisers, at least, believe it is. But beyond the salutary
effect advertising may have on a single institution, what is
the cost of healthcare advertising for the healthcare system as a whole?
When hospital advertising first became widespread,
one of the most pervasive justifications for its use was that
it was not advertising at all; it was simply education.7,8 Advertising, it was argued, was a way for hospitals to educate the public on the need or availability of vital healthcare services. Defenders reasoned that it was not a matter
of stimulating demand but rather of increasing utilization.
While admittedly there are instances in which healthcare
service advertising has increased the demand for necessary
and efficacious services, it is just as likely to promote expensive, unnecessary, or inefficacious ones; for example,
the aggressive advertising of whole-body computed to-
Recent studies of healthcare service
advertising reveal that medical centers
and individual physicians often create
advertisements that manipulate patients’
ignorance and vulnerability and stimulate
demand for unproven or ineffective therapies
mographic and magnetic resonance imaging screening
tests (a procedure whose benefit has never been proven
and that may expose patients to invasive and costly follow-up tests).1,3,9
Admittedly, the costs of these screening tests are
borne by the individual consumer, but the expensive and
often unnecessary followup testing they may provoke are covered by all of
us. Evidence also indicates
that hospital advertising
may (in part) be responsible for the public’s demand
for costly and ineffectual
treatments around the end
of life, given the perception that higher technology and more advanced procedures are always better.1,9
We shouldn’t be surprised that the expansion of
healthcare advertising has led to this situation. In essence,
healthcare institutions that advertise without regard to the
actual need for their products or services are simply behaving the same way more obviously commercial enter-
prises do. General Motors Corp. doesn’t need to consider the actual transportation needs of the public when it introduces a new car—only whether or not the company
can sell it. By the same token, without standards for
healthcare advertising that explicitly address the effect
these advertisements may have on demand for unnecessary services, promotion of these often-profitable services
will only continue and grow.
THE COSTS OF COMPETITION
Supporters of healthcare advertising also suggest that advertising is good for the healthcare consumer. They cite
marketing theorists’ contentions that by providing the
public with free and useful information, advertising lowers search costs—the costs associated with finding a good
or service—and makes consumers more sensitive to prodCONTINUED ON PAGE
THE HOSPITALIST
> JANUARY 2007
20
19
HOSPITAL ADVERTISING > CONTINUED FROM PAGE 19
uct characteristics. The consequence, they contend, is that
advertising not only ultimately lowers consumers’ cost,
but it can also drive an increase in quality.10 These observations may have some merit with other sectors of the
economy; they have little relevance in healthcare.
First, aggressive and well-funded advertising can easily overwhelm the disincentive of purchasing low-quality
goods or services—particularly in a field like healthcare, in
which quality is so difficult to measure objectively. Further, in an area like healthcare, in which there are legal restrictions on price competition and consumers typically
pay through a third-party intermediary, there is little if
any room for advertising to promote lower costs. The fact
is that healthcare advertising is more likely to be inflationary.
When a hospital spends money to promote its new
open-heart surgery program, it is most likely competing
with other institutions for the same pool of patients. Be-
cause the supply of potential consumers of this service is
limited, other institutions will be forced to spend more
money promoting their own programs simply to maintain the market share they already have.11 As a result, advertising by one institution only increases pressure on advertising budgets across the board—a situation that
inevitably leads to higher costs universally.
Advocates of healthcare advertising also argue that it
can be good for the community. They argue that advertising may increase revenue for a healthcare institution,
thus enabling the institution to more vigorously pursue
its mission. Because the demand for legitimate healthcare
services remains relatively fixed, however, the only growth
healthcare advertising typically creates comes at the expense of a competitor.12 The consequence of this “zero
sum game” becomes starkly apparent when one considers
that hospitals and medical centers tend to compete only
for the most well-insured or affluent patients. There is lit-
tle healthcare advertising directed at conditions that disproportionately affect the poor or uninsured. Hospitals or
medical centers with the best or most aggressive advertising campaigns tend to “cherry-pick” the highest-paying
patients, leaving those patients who are less likely to pay
concentrated at centers that are unable to compete. This
concentration of poorly reimbursed or free care at institutions struggling to maintain financial viability can, over
time, lead to lower quality and, if the institutions fail, decreased access for the most vulnerable.
CONCLUSION
With economic pressures and competition for healthcare
expenditures growing, hospitals and individual physicians
will continue to look to advertising healthcare services as
a means to increase revenue. Yet patients are fundamentally different than other types of consumers. Given the
typical patient’s combination of vulnerability and inequity
of knowledge, it is clear that healthcare
consumers deserve special protection
from advertisements that play to emotions or ignorance.
Additionally, because we as a society
collectively foot the bill for healthcare
costs, we must think about whether we
can count on individual hospitals and
healthcare providers—with their own
narrow financial agendas—to abstain
from advertising that unnecessarily promotes increased expenditures and costs.
More studies on the direct costs of
healthcare service advertising need to be
done, and more light needs to be shed on
the effects of the millions of dollars advertisers spend annually. Some advertising of medical services may indeed be
necessary, but it cannot be allowed to
threaten informed patient decision-making or the economic viability of our
healthcare system. TH
Dr. Oxman is a hospitalist, a critical care and infectious
diseases fellow in Boston, and a former fellow in medical
ethics at Harvard.
REFERENCES
1. Larson RJ, Schwartz LM, Woloshin S, et al. Advertising by academic medical centers. Arch Intern Med.
2005 Mar 28;165(6):645-651.
2. Finn R. Hospital marketing practices: when is it appropriate to advertise new technology? J Natl Cancer Inst.
2001 Jan;93(1):6-7.
3. Illes J, Kann D, Karetsky K, et al. Advertising, patient
decision making and self-referral for computed tomographic and magnetic resonance imaging. Arch Intern
Med. 2004 Dec 13-27;164(22):2415-2419.
4. Latham SR. Ethics in the marketing of medical services. Mt Sinai J Med. 2004 Sep;71(4):243-250.
5. Greer S, Greenbaum P. Fear-based advertising and the
increase in psychiatric hospitalization of adolescents.
Hosp Community Psychiatry. 1992 Oct;43(10):10381039.
6. McKneally MF. Controversies in cardiothoracic surgery:
is it ethical to advertise surgical results to increase referrals? J Thorac Cardiovasc Surg. 2002
May;123(5):839-841.
7. Berger JD. The ethical side of advertising. Hosp
Forum. 1981 Nov-Dec;24(6):35, 38-39.
8. Bonner JW III. Hospital advertising. Hosp Community
Psychiatry. 1993 Apr;44(4):391-392.
9. Manning S, Schneiderman LJ. Miracles or limits: what
message from the medical marketplace? HEC Forum.
1996 Mar;8(2):103-108.
10. Hammond KL, Jurkus AF. Healthcare professionals
and the ethics of healthcare marketing. Health Mark
Q. 1993;11(1-2):9-17.
11. MacStravic RE. Should hospitals market? Hosp Prog.
1977 Aug;58(8):56-59, 82.
12. Parrington M. The ethics and etiquette of marketing.
Healthc Forum J. 1989 Jan-Feb;32(1):42.
20
THE HOSPITALIST
> JANUARY 2007
Certified Nurse-Midwife Emalie Baker
cares for an expectant patient.
Nurse-midwife
laborists add value
to hospital-based
care models
❚❘ By Rima Jolivet, CNM, MPH
E
malie Gibbons Baker, CNM, arrives at St Mary’s
Hospital at 7 a.m. Half an hour later she is
scrubbed in, first assisting a community OB/GYN
who performs a repeat cesarean delivery. By 9 a.m.,
the baby is safely delivered and resting with his mom, and
the physician is seeing patients in her private practice a few
miles from the hospital.
Now Baker cares for a nervous first-time mother in
labor, sitting close to her bed and softly encouraging her
through each contraction, praising her efforts when each
pain subsides. She steps out to monitor an outpatient who
has arrived for a labor check, performs a sterile speculum
exam, and confirms the well-being of the fetus. Then reviews the signs of labor with the expectant mother, gives her
a pep talk and a hug, and discharges her.
This is a typical start to a busy day for Baker, a certified
nurse-midwife (CNM) laborist at St. Mary’s Hospital in
Leonardtown, Md. CNM laborists like Baker work cooperatively with their collaborating physicians and midwife colleagues in the ambulatory setting and in the hospital, leaving
their colleagues with time to care for high-risk women in the
hospital and to hold office hours in their private practices.
Like most CNM laborists, Baker provides care during
labor and the post-partum period for pregnant women and
new mothers in the hospital setting. She oversees labor induction, augmentation, and pain management, including epidurals, for patients on the ward, works with the nursing staff,
provides hands-on care for patients, provides first assists in cesarean deliveries, and evaluates pregnant patients who present
to the emergency department (ED). When a new need arises,
Baker can often provide the necessary service, and the list continues to grow as she adds circumcisions and interpretation of
fetal fibronectin results to her responsibilities.
SKILLED LABORERS
Certified nurse-midwives are a valuable addition to the field
of hospital-based healthcare. The approximately 7,000 practicing certified nurse-midwives in the United States delivered more than 310,000 babies in 2003, representing more
than 10% of the vaginal deliveries in this country.
Many people are unaware that 98% of CNM-attended deliveries in the United States occur in a hospital. Certified nurse-midwives are qualified professionals who have
graduated from an accredited university-based program and
passed a national certification exam. Baker, like all CNMs,
is a registered nurse. She earned her master’s degree in midwifery in 1994 at State University of New York Downstate
CONTINUED ON PAGE
THE HOSPITALIST
> JANUARY 2007
22
21
SKILLED LABOR > CONTINUED FROM PAGE 21
University, one of 40 midwifery education programs in the United States.
Certified nurse-midwives practice in a variety of settings, including
hospital and office-based practices,
community health centers, and public health facilities. CNMs are licensed in all 50 states. They are reimbursed by Medicare, are
Medicaid-mandated
service
providers, and are widely included in
managed care provider listings.
CNMs are experts in the management of normal birth. Studies have
demonstrated that the outcomes of
nurse-midwifery care are at least
equivalent to those of patients managed by physicians for normal maternity care, and patients repeatedly indicate
high levels of satisfaction
with the care provided by
nurse-midwives.
“Having [Baker] at
the hospital has been a big
selling point for patients.
She helps by massaging the
patients who are anxious
or need things explained
to them. I think this provides the patients with a
sense of security, and they
also appreciate that this is
a unique and different
service we provide here,”
says Valinda Nwadike,
MD, an OB/GYN at St.
Mary’s County who previously worked with nursemidwives in a large urban
hospital in Washington,
D.C. “All in all, having
[Baker] on board as a
CNM laborist means better patient interaction and
increased quality and continuity of care. It is a very
useful tool, one that improves both patient care
and our quality of life as
community physicians. It’s
a win-win situation.”
Emalie Gibbons Baker, CNM
FILLING THE GAP
The Southern Maryland
community served by St.
Mary’s Hospital is quickly
growing. The hospital
serves as the birth site for
the nearby Patuxent Naval
Air Station. The number of
births at the 100-bed facility recently jumped from
600-800 births a year to
more than 1,000. The four
OB/GYNs serving this
county of 90,000 are all in
private practice. With
growing businesses, these
community
providers
found that juggling busy
outpatient schedules with
inpatient demands for
labor support or hospitalbased procedures was resulting in disruption in
their clinics, lost revenue,
and frustration for them
and their patients alike.
Collectively, the community OB/GYNs got together and decided to hire
22
THE HOSPITALIST
> JANUARY 2007
a CNM laborist to help cover the
bases. Lawrence Tilley, MD, chief
of obstetrics and gynecology at the
hospital, had watched the success
of the hospitalist model at St.
Mary’s and has a certified nursemidwife on staff at his private office. He finds that offering nursemidwifery services in his practice
acts as a draw for patients. At the
hospital, he would like to add more
midwives to the staff, for 24/7 coverage.
Hundreds of miles away, in a
busy urban healthcare delivery system with different needs and
rhythms than those in rural Mary-
land, the CNM laborist model also fits the bill. At Mt.
Sinai Hospital in Chicago Laborist Darryn Dunbar,
CNM, attends the births of nurse-midwifery patients
served by the Access Community Health Network, a large
healthcare organization that manages 44 Federally Qualified Health Centers in the Chicago area. The hospital sees
4,000 births a year, of which close to 10% are attended by
midwives. Dunbar is one of two CNM laborists at Mt.
Sinai who care for Access midwifery patients, most of
whom are on Medicaid. He works solely in the hospital,
providing inpatient coverage after hours and on weekends
to the clients of a seven-midwife team that, with the addition of his laborist services, is able to offer almost continuous midwifery coverage.
“The goals were to extend midwifery coverage, to increase patient satisfaction and safety by having continuity
of on-site care for this group of patients, … to improve
As experts in caring for healthy women and
their newborns, with a history of
achieving excellent perinatal outcomes
while caring for underserved populations,
certified nurse-midwives are ideal
healthcare providers for women who
arrive at hospitals seeking quality care.
staffing ratios in labor and delivery, and [to] provide relief
for the residents and house officers,” says Dunbar.
His many years of experience as a full-scope CNM in
busy, urban settings with high volume and increased social and medical risk factors make him well suited to pro-
viding care in this setting.
In addition, in Illinois (as
of this year) Dunbar can
bill directly for his services
under Medicaid and receives 100% of the physician reimbursement rate.
He can also serve as the
billing provider when he
supervises the deliveries of
residents in the hospital
training program.
Dunbar is a valuable member of the OB team. He
receives patients who come in through the ED and helps
with OB triage, first assists with cesarean deliveries on occasion, and “runs the board” when the residents are off
the floor for educational obligations, are in surgery, or are
busy with other patients. The nursing staff, house attendings, and residents have all come to rely on his watchful eyes and helping hands.
Nurse-midwives, according to their professional philosophy, believe the best model of healthcare for a woman
and her family is one that promotes a continuous and
compassionate partnership, including individualized
methods of care guided by the best evidence available,
therapeutic use of human presence, and skillful communication. They believe in watchful waiting and non-intervention in normal processes, the appropriate use of interventions and technology for current or potential health
problems, and consultation, collaboration, and referral
with other members of the healthcare team, as needed, to
provide optimal healthcare.
The ability to provide this kind of care is one of the
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Fast Facts about
Nurse Midwives
• Certified nurse-midwives are registered nurses who have completed an additional graduate-level midwifery education program at one of 40 programs across the United States and who have passed a
national certification exam.
• Nurse-midwifery practice is legal in all 50 states, the District of Columbia, American Samoa, and
Guam.
• Nurse-midwives have prescriptive authority in 49 states, the District of Columbia, American Samoa,
and Guam.
• America’s 7,000 certified nurse-midwives attended more than 310,000 births in 2003, according to
the National Center for Health Statistics. More than 98% of CNM-attended births occur in hospitals.
• More than 50% of CNMs list physician practices or hospitals as their principal employers.
• Thirty-three states mandate private insurance reimbursement for nurse-midwifery services, and Medicaid reimbursement is mandatory in all states.
• Employers seeking a certified nurse-midwife can post their job listings on www.MidwifeJobs.com.
• Learn more about certified nurse-midwives at www.midwife.org.
greatest strengths certified nurse-midwives bring to the
communities they serve, especially in busy hospitals where
the healthcare needs of women and their newborns are
great and the demands on providers’ time are high.
Struggling to increase patient safety, decrease costs,
and optimize productivity while maintaining good health
outcomes, hospitals are increasingly turning to nurse-midwives. Meanwhile, many community OB/GYN providers
are reducing their OB call due to burnout and quality of
life issues, increased liability insurance premiums, and fear
of litigation. Resident work-hours have decreased due to
safety concerns and mandated work limits. There is a need
for providers who can care for laboring women in the hospital setting, providing continuity and quality of service
during their hospital admission. On-site CNM laborists
fill in the gap.
INCREASE SAFETY AND QUALITY
Having a laborist on board in the OB/GYN department
of the hospital helps Yaacov Zamel, MD,
a pediatric hospitalist at St. Mary’s, by allowing him to establish a working relationship with someone whose availability
and practice patterns he can rely on. He
also notes that this improves care for the
women and babies. “The better the support for OB, the better it is for newborns.
Ultimately, more patients will want to
come here,” says Dr. Zamel.
Dr. Nwadike agrees that having a
nurse-midwife on staff increases patient
safety and the quality of care. “In our
community, we needed help specifically
with coverage for hospital patients and
procedures, and Baker’s skills are the perfect match,” says Dr. Nwadike. “Now she
is an invaluable resource and can do all of
those things, as well as provide ED triage,
care for unassigned patients, or manage
precipitous deliveries. As a continuous
presence on labor and delivery, she is a
great resource for patients and can provide them with more depth, more education. There are really limitless possibilities for her role to expand.”
As experts in caring for healthy
women and their newborns, with a history of achieving excellent perinatal outcomes while caring for underserved populations, certified nurse-midwives are
ideal healthcare providers for women
who arrive at hospitals seeking quality
care. “Working as a laborist, I enjoy being
able to use all of my skills. That has been
very exciting,” says Baker.
At 4:30 p.m., Baker wraps up for
the day. The community OB/GYN on
call arrives from his office to assume
care for a laboring patient on his panel.
Baker updates him on the woman’s status, than wraps the patient in a warm
parting hug. TH
Rima Jolivet is the senior technical advisor at the American College of Nurse-Midwives.
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Charts to
Screens
Rights were not granted to include this image in electronic
media. Please refer to the printed publication.
❚❘ By Gretchen Henkel
The challenges of IT adoption and how hospitals manage it
F
ederal policy makers have set 2014 as the target year for all
Americans to have an electronic health record. While researchers claim that health information technology (IT) holds
great promise to improve the quality and efficiency of healthcare delivery, the path to effecting the transition to computer-based
documentation systems is fraught with obstacles. In addition to large
initial capital investments for upgraded hardware and software, hospitals face other barriers to IT adoption. The challenges experienced
by hospitals making this change include steep learning curves, workflow disruptions, and time delays.
The biggest mistake you can
make is to have physicians feel
that you’re forcing something
down their throats that slows
them down.—Richard Todd, MD
ADVANCEMENTS AND GLITCHES
A 2005 American Hospital Association (AHA) survey of 900 community hospitals found a wide range of IT usage. Some hospitals have
completed installation of bar coding for medication management,
while a small minority are using advanced computerized physician
order entry (CPOE) systems.1 Typical of many hospitals in the AHA
survey, Abbott Northwestern Hospital in Minneapolis chose an incremental IT implementation approach.
Academic hospitalist Debra L. Burgy, MD, is the lead physi-
cian in Abbott Northwestern General Medicine Associates Group,
affiliated with the internal medicine program at the University of
Minnesota (Minneapolis), where she is also adjunct assistant professor of medicine. Hers was the first group of physicians to go live
with the hospital’s electronic documentation system 16 months ago,
in July of 2005.
“We went up on July 1 because we thought it might be an advantage to have a long weekend with a lower census,” she recalls. As
it turned out, her group of academic hospitalists was caught shortstaffed on the holiday weekend, having to adjust to their new IT roles,
take care of patients, and orient the brand-new interns.
“It was kind of a sad weekend for me,” she remarks wryly.
Of the launch in July 2005, Dr. Burgy observes that the learning curve “was longer than I expected, but once you achieve it and
you’re adept at most of the functions I do find [electronic documentation] better overall in many ways.”
One advantage: As an academic hospitalist, she consults with her
residents and emergency department admitting physicians in real time
by pulling up patients’ charts from any location.
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CHARTS TO SCREENS > CONTINUED FROM PAGE 25
Dr. Burgy and her colleagues still
find the time required to enter the narrative part of the patient’s history of present illness difficult, as well as the discharge notes. Another bug: The system is
designed to prompt the physician to complete medication reconciliation (Medication Administration Record, or MAR) at
admission, transfer, and discharge. Because the medications are not organized
in alphabetical order or side by side, however, the logistics of reconciling more
than a few medications can be frustrating.
“Most of us end up printing out the
current MAR, which seems to defeat the
purpose of the computerized record,” says
Dr. Burgy.
A STAGED APPROACH
According to Mary A. Dallas, MD, chief medical information officer for Presbyterian
Healthcare
Services (PHS), an integrated healthcare delivery
network in Albuquerque,
N.M., PHS launched
CPOE in the main hospital’s inpatient services area
as the final step in the
pharmacy
automation
process designed to improve patient safety and
prevent medication errors.
Five years ago, the
main hospital began the
process of developing a
closed-loop
pharmacy
order system. Now, with
this system in place, medication orders go directly
from the physician’s fingertips to a pharmacy work
queue. The verified drug
order is then messaged to
the pharmacy robot for
packaging. On the floor,
nurses’ hand-held devices
flash a message that the
drug order is ready. Upon
delivery to the floor, a
nurse scans the bar code on
the packaged medication,
matches it to the patient’s
bracelet bar code, and scans
his or her badge before administering the medication. This verifies the 5
“Rs” of medication safety:
right medication, right
dose, right route, right patient, and right time, as
well as concurrently creating the electronic MAR.
As the former medical
director of the hospital’s
Adult Hospitalist Service,
Dr. Dallas understands the
physician’s point of view.
When launching the hospital’s CPOE, she was aware
that, “especially in the hospitalist arena, we were
adding some extra learning
curve to their day.”
She also admits, “It
does take longer to log
onto a computer system
and wait for the program
to boot than it does to just
scribble a medication order
on paper. There’s no way to
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avoid that.”
As she has worked to build order sets
tailored for various specialties, however,
Dr. Dallas has been sensitive to challenges
that can be softened. Automatic prompts
at the point of order entry are carefully
monitored, she points out because “surplus of medication” alert pop-ups can
sometimes produce physician “alert fatigue,” and doctors may begin to ignore—
rather than address—the alerts. “You have
to start light and then work to get more
stringent as people tolerate and get used
to that system,” she says.
GETTING PHYSICIAN BUY-IN
Mary A. Dallas, MD
The launch of the CPOE system at Pres-
byterian Hospital in Albuquerque was the fourth such experience for Richard Todd, MD, medical director of the
hospital’s Adult Hospitalist Group. He sees speed—or the
lack thereof—as a major barrier to physician adoption of
computerized documentation systems. He has observed
that some hospitals don’t invest in the appropriate hardware required to handle such technically demanding software. As a result, a user may have to wait 25 or 30 seconds
for an order entry system to boot up.
“That is an eternity in computing time,” he says, and
a physician who experiences this difficulty more than
twice may no longer have the patience to work with the
system.
Physicians should be part of the IT design and selection process, Dr. Todd believes. “To get a successful
adoption by physicians, the engineers need to come to the
physicians’ table and not the other way around,” he says,
As a result of going digital, Saint Clare’s
Hospital has 99.6% compliance with
formulary medications, notes zero
transcription errors, and averages 10 minutes
from order to administration of stat antibiotics.
pointing to the success of Wiz Order, Vanderbilt University School of Medicine’s order-entry system, which is part
of an electronic medical record custom-built with input
from doctors.
“The biggest mistake you can make is to have physi-
cians feel that you’re forcing something down their
throats that slows them
down,” says Dr. Todd.
“Every physician is under
tremendous time pressure
to get the primary job
done, so if you do anything that even makes
them perceive that it’s
going to make them less efficient, you’re not going to
get buy-in.”
S. Trent Rosenbloom, MD, MPH, trained as an internist and pediatrician and spent some time as a hospitalist early in his career. Currently, he is assistant professor in the departments of Biomedical Informatics,
Internal Medicine, and Pediatrics, and in the School of
Nursing at Vanderbilt University Medical Center. He and
his research colleagues have investigated the factors which
influence providers’ perceptions of clinical documentation tools.2
“The key issue is not so much time, but the perception of time and work flow,” he explains. “It [a computerized documentation system] could be twice as fast, but
if I have to go out of my way to do it, then I might perceive it as taking more effort and more time.”
For instance, writing a drug order on paper can appear to be a faster process than finding a computer, sitting
down, logging on to the system, finding the patient in the
menu, opening the patient file, and then entering a drug
order. Dr. Rosenbloom points out that when physicians
think about these two processes, however, they may not
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factor in the other time factors for the paper order, such
as walking to the chart, finding the chart, turning to the
right page, and entering the drug order. And although
computer systems are not error-free, CPOE tends to reduce transcription and other errors that in themselves can
be time-consuming, if not life threatening, for the patient.
I was one of the most
computer illiterate people I
knew. But somehow, I got
thrown into the role [of IT
adoption]. We took a potential lemon, embraced it early
on, and made lemonade.
—Richard H. Bailey, MD
KEYS TO SUCCESS
Sources agreed that IT adoption by physicians increases in
direct proportion to their participation in the process.
“[Hospitalists and other physicians] need to make sure
that their hospital includes physicians in every step of the
due diligence process: looking through systems, going to
the sales, actually banging on the product, and making
sure that they perceive it as meeting their needs,” advises
Dr. Rosenbloom.
Vendors differ in
their methods for bringing client hospitals online. “A staged approach is probably
best, based on what we know currently,” he suggests.
Finally, flexibility is key—for vendors and users. Dr.
Rosenbloom advises teams to “expect to fail, and learn
from that.” It’s important to recognize, he says, “that even
if you’re putting in a computer system that has been implemented in 50% of hospitals—which hasn’t yet happened—there are idiosyncrasies and differences in your
own center that will cause the implementation process to
be different.”
Given hospitalists’ interest in hospital processes,
leading the IT adoption effort is a natural role for hospitalist leaders, believes Richard H. Bailey, MD, medical director of Inpatient Care and Hospitalist Services at Saint
Clare’s Hospital in Weston, Wis. “I was one of the most
computer illiterate people I knew,” he relates. “But somehow, I got thrown into the role. We took a potential
lemon, embraced it early on, and made lemonade.” TH
Gretchen Henkel also writes about benchmarking hospital
medicine programs in this issue.
REFERENCES
1. American Hospital Association. Forward momentum:
hospital use of information technology. October 2005.
Available at: www.aha.org/aha/research-andtrends/AHA-policy-research/2005.html. Last accessed November 29, 2006.
2. Rosenbloom ST, Crow AN, Blackford JU, et al. Cognitive factors influencing perceptions of clinical documentation tools. J Biomed Inform. 2006 Jul 8; [Epub
ahead of print].
Going All
Digital
Richard H. Bailey, MD, is in a unique
position at Saint Clare’s Hospital in
Weston, Wis. As medical director of
Inpatient Care and Hospitalist Services, he was in charge of designing
his team around a completely electronic system of documentation,
order entry, and health records when
the brand-new, 107-bed state-of-theart facility opened in October 2005.
The hospital started out “100%
CPOE and has been going strong
since,” he says. As a result, the hospital has 99.6% compliance with formulary medications, notes zero transcription errors, and averages 10
minutes from order to administration
of stat antibiotics. As a hospitalist, Dr.
Bailey especially appreciates the ability he now has to converse with patients’ primary care physicians in
neighboring towns, while simultaneously viewing patient records, tests,
and X-rays online.
All these benefits are the result
of a heavy time commitment on the
part of everyone involved. Using elements from some vendor-distributed
products, the hospital added niche
products to the foundational system,
yielding what Dr. Bailey characterizes
as a “best of breed” electronic health
information system. He invested significant work developing order sets,
embedding in them clinical protocols
and guidelines, and participating in
process mapping all hospital procedures.
To help with the huge learning
curve of going up on the new system, the CPOE steering committee,
which he led, added a physician
user group and appointed key staff
to be “super-users” of the new system. They then scheduled superusers to be on every ward for every
shift, to “rescue physicians at the first
sign of question.”—GH
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A Stake in the
Sand
Rights were not granted to include this image in electronic
media. Please refer to the printed publication.
The SHM
survey:
a tool for
benchmarking
hospital medicine
practices
❚❘ Gretchen Henkel
CONTINUED FROM PAGE
1
as pitfalls, cautions Joe Miller, SHM senior vice president and principal analyst of the survey data. He emphasizes the great variation
among hospital medicine groups and warns against looking at survey medians as representing a “typical” hospital medicine practice.
“When you’ve seen one hospital medicine group, you’ve seen
one hospital medicine group,” he quips. In several recent conversations, hospital medicine group leaders and SHM leaders involved in compiling the survey discussed the survey’s strengths
and limitations as a benchmarking tool.
HEALTHY TO NEGOTIATE
According to the survey 97% of hospitalist programs receive some
type of financial support. “Virtually every program in the country is
challenged to defend the amount of money [they receive] or to negotiate for support dollars,” says Miller, who believes that negotiation
can be a healthy dynamic. “There is a sense of equality of both sides
of the table, a mutual respect between hospitalists and the hospital.”
In the process of such negotiations, it will be important not to pin
one’s position entirely to the survey metrics.
John Nelson, MD, medical director of the hospitalist practice
at Overlake Hospital in Bellevue, Wash., a consultant for hospitalist practices with Nelson/Flores Associates, a columnist for The Hospitalist (“Practice Management”), and a co-founder and past president of SHM, believes that some hospitalists mistakenly view the
survey as SHM’s position on what a hospitalist should make. “The
survey is the best information we have about what hospitalists do
make—there is no better source—but it’s still a survey.”
Using compensation medians as yardsticks for actual salaries
and compensation packages is analogous to “learning the average
weight of an American and deciding that’s what we all should
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weigh—and that’s a big mistake,” he says. “If you hold up
the survey as the governing document, then each party will
use it to their advantage.”
Because the survey is regarded as the most authoritative
existing source on hospitalists’ compensation and productivity, it nevertheless ends up being used as a benchmark,
says Robin L. Dauterive, assistant director of the clinical hospitalist service at Massachusetts General Hospital in Boston.
“Whenever I’m preparing billings reports or dashboard
measures—anything that shows my group’s workload—
sooner or later, I always have to include something in there
that states, ‘This is what other people are doing,’ ” says Dauterive. “It’s something that you can’t get away from, unfortunately, in medicine.”
She realizes that the survey does not purport to set any
national standards, and yet, “all administrations want comparisons.” Dr. Nelson has also noted this phenomenon with
the survey. In the absence of
additional guidance, hospital executives and hospitalists often find that they’re
just arguing about the survey. “And that’s unfortunate,” he says. “It means
they’ve lost sight of the
unique attributes of a given
practice that might support
higher or lower incomes and
higher or lower workloads.”
VIEW IN CONTEXT
Hospitalists reading the survey for the first time might
first seek to analyze the
metrics regarding billings
and collections. Here it is
especially important not to
view the reported numbers
in isolation, says Dr. Nelson. For instance, to learn
how a hospitalist’s annual
gross charges (billings)
compare with others across
the country (question 12 of
the Individual Hospitalist
questionnaire—p. 87, Appendix 2), details on pages
251 and 252 supply pertinent variables. For instance,
in comparing the four regions of the country, Table
056-A shows that the median annual gross charges for
physicians in the south are
highest, at $354,000. Hospitalists compensated by a
100% incentive method report higher charges per year
($392,000) than those who
are on a 100% salary or a
mix of the two methods of
payment. Turning to Table
056-B, on page 252 of the
published survey, hospitalists can find annual gross
charges according to practitioner type, specialty, and
employment model. Hospitalists should not stop
their reading there, however, as a comparison of others’ annual gross collections
might give a more complete
picture.
Still, the SHM Survey
does not reference all possible explanatory variables.
Collections can be influenced by location and payer
mix. Hospitalists practicing
in a large urban hospital are
likely to see more indigent
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THE HOSPITALIST
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patients for whom the hospital is not reimbursed. A careful
reading of the survey should include the questionnaire and
the tables supporting chapter conclusions, and the reader
must recognize the survey’s limitations.
APPLES TO ORANGES
IPC–The Hospitalist Company participates in the SHM survey and also uses it as a recruitment tool, reports IPC Vice
President of Physician Staffing Timothy Lary. “We look at
the income averages, and we’re able to demonstrate how our
averages are, for the most part, higher than the averages,” he
explains. “We also look at the survey from an internal viewpoint, but oftentimes you are comparing apples to oranges.”
Like individual hospitalists, hospital medicine group
leaders seek comparisons when they read the survey. For her
part, Dr. Dauterive has found the data on starting salaries for
new hospitalists useful. For example, page 259, detailed table
060-A on hospitalists’ compensation by category and total,
breaks out median yearly income by years as a hospitalist,
from less than a year to six or more years. (Many of the detailed “A” tables in Chapter 8 on compensation include the
“years as a hospitalist” category.) Dr. Dauterive praises the
wealth of data in the survey, pointing to examples of the
many variables she was surprised to learn. One of those factors was that 48% of surveyed hospitalist programs were at
non-teaching hospitals. (See page 7 of the survey, Executive
Summary, “Teaching status of affiliated hospital.”)
Those interviewed for this article agree that productivity data are probably more telling about the day-to-day clinical realities for hospitalists. Productivity metrics figure
prominently in Dr. Dauterive’s uses for the survey. Accordingly, the annual number of billable patient encounters seen
by the hospitalist (Table 58-B, page 256) and the annual
number of work relative value units (RVUs) worked by the
hospitalist (Table 59-B, page 258) caught her interest.
Still, Dr. Dauterive found herself wanting more data
to shed light on those numbers. In negotiations for resources with hospital administrators, Dr. Dauterive would
like to be able to pinpoint the reasons behind reported
numbers of clinical encounters seen by the hospitalist. If
the median number of billable patient encounters seen by
the hospitalist in a teaching service was 1,668 (based on
107 responses; page 256, Detailed Table 058-B), what
were some of the influences on this number? What was
the acuity level of patients? Did the hospitalist have group
resources, such as physician extenders, to help with patient admissions and rounds?
“For groups that have low lengths of stay, it would be
important for me to know why,” she says. “Did they have
extra supports? Do their [doctors] use Palm Pilots? You don’t
always know from looking at the numbers how to apply
them, make the connection, and justify the resources you’re
trying to achieve,” she says.
NO PERFECT MEASURE
The ideal survey for Dr. Dauterive would include specific
structured models, providing links between categories so
that she could compare characteristics that more closely
align with her group’s situation.
“Our program is very mixed, so it would be helpful for
me to know how work RVUs were being reported,” she says.
Pointing to results showing higher productivity (work
RVUs) in practices compensated by 100% incentive (Table
060-A, page 259 of the survey), Dr. Dauterive wonders what
factors drive these results. While the 100% incentive might
appear to be the most important factor, perhaps these groups
also have physician extenders or are located in a geographic
location that boosts their productivity.
“I’m in a nonprofit hospital, in a clinical hospitalist
service, and I want to be able to approach the administration
and say, ‘If you want us to see the most patients, these are the
kinds of services that see the most patients,’ ”says Dr. Dauterive. “But, if you are more interested in physician retention
and work/life, then these are the characteristics of those successful programs.”
This level of detail can be difficult to interpolate from
the survey, agrees Dr. Nelson. Patient acuity, for instance, is
not specifically queried in the survey questionnaire. “I agree,
in the ideal world, this is all information that you would
want to know,” he says. Answers to the following questions
could help refine product metrics:
• Does your group have teaching responsibilities for
residents?
• Do you take a lot of calls from home, or do you have
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A STAKE IN THE SAND > CONTINUED FROM PAGE 31
a separate night shift?
• Do you cover more than one physical hospital on the
same day?
• Does your group do more than the typical amount of
committee and administrative work?
“All these factors,” notes Dr. Nelson, “would influence
productivity. There is no perfect way to know the answer to
any of those things.” And, he adds, the survey already comprises 292 pages, including numerous detailed tables of data.
To include all pertinent variables would entail a longer questionnaire, which might affect the response rate.
HEALTHCARE DELIVERY IS LOCAL
In his consultations with hospitalist groups, Dr. Nelson always emphasizes that the survey is “a starting point” and not
the goal of what hospitalists should make. He favors ad-
junctive methods for benchmarking practices: “I think that
when you’re benchmarking your practice, it’s as important
to gather as much local and regional data as you can—in
addition to the SHM survey.” He tries to network with
other Seattle hospitalist programs to learn about their patterns of work hours, patient loads, and the like.
Thomas Baudendistel, MD, FACP, associate program
director of the Internal Medicine Residency Program at Sutter Health’s California Pacific Medical Center in San Francisco, notes that regional markets differ widely. The healthcare market in the Northern California Bay area is very
different from the one in Los Angeles in terms of financial
remuneration and incentivization.
“The survey,” he says, “gives a global gestalt of the regional flavor of hospital medicine” and reveals general ballpark medians that can be a good starting point for practice
benchmarking. “I think what our administration [at California Pacific Medical Center] wants to see is our data compared to the people across the street and down the road, because that’s a closer comparison in terms of payer mix and
insurance reimbursements.”
IPC’s Lary agrees. “When I compete, I don’t compete
against people across the country; I compete with people
across the street,” he says. “As large as IPC is, we realize that
healthcare is delivered locally. What we try to do [with the
survey] is take the information and, to the best or our ability, figure out how it applies to our individual settings and
[to the] different markets that we are in.”
A STAKE IN THE SAND
“I think the benchmarks we have in the survey are just a
piece of information—[the survey] is a context, it’s a stake
in the sand,” concludes Miller. “We do have
variations by type of program, by size of hospital, by geographic location, by size of program. There are numbers for each one of
those, and you can clue in as to what some
of the more important variations are. We
could list probably 25 to 50 variables that
would affect hospitalists’ productivity in one
way or the other—and that’s not taking into
account the individual styles of hospitalists.”
For instance, some hospitalists want to
work and earn as much money as possible,
while others are searching for a work/life balance that will allow them time with their
families.
The survey, says Lary, supplies a piece
of information in a complex puzzle about a
highly variable profession. “There are so
many different ways this business is being
conducted right now,” he says. “One medical community may be willing to subsidize
a hospital medicine program, and another
may not be willing.”
Hospitalists’ professional goals vary
widely as well. As far as Dr. Nelson is concerned, the bottom line for hospitalists is to
structure independent practices tailored to fit
their goals. This means that hospitalists are
connected to the economic consequences of
their staffing and workload decisions. In that
way, he says, rather than approaching administrators about hiring more physicians,
the practice itself can decide whether it is
worth the decrease in individual hospitalists’
incomes to hire another doctor.
Because their specialty is still evolving,
hospitalists will find themselves educating
their clients about the profession’s services
and advantages. And for that process, the survey can be a helpful adjunct. Miller agrees
that the use of the survey requires a certain
amount of interpolation on the part of hospitalist leaders. They should be careful, he
emphasizes, not to lose sight of the individuality of their own practices.
“If you hold up the survey as the governing document when you negotiate with
your hospital, then each party will use it to
their advantage,” says Dr. Nelson. “This
can push you towards being ‘average’ when
that might not be appropriate for your
practice.” TH
Gretchen Henkel is a frequent contributor to The Hospitalist.
For More Information …
The Executive Summary of the 2005-2006 SHM Survey is available online at the SHM Web site: www.hospitalmedicine.org. (Click “SHM Survey” in the lower
left-hand corner of the home page; order information is
available by clicking on the order link.)
SHM members as well as non-member hospitalists who participated in the survey should have already received a free CD containing the contents of the
published survey. For printed versions of the survey
book, the charge is $50 for member respondents and
$350 for non-member respondents.
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BIAS
MEDICINE
in
What you don’t see can hurt you (and your patients)
❚❘ By Andrea M. Sattinger
I
Rights were not granted to include this
image in electronic media. Please
refer to the printed publication.
definitely think there may
be some biases on the part of
hospitalists,” says Ashish
Boghani, MD, chief of the
hospitalist service at Highland
Hospital, Rochester, N.Y. As a
young physician, he noticed some
bias in his own thoughts and behaviors.
“But as I got more and more
experienced,” he says, “if I was
told by another provider that
someone was a difficult patient, I
left that outside the door. When I
go into a patient’s room the first
time, I start fresh—no matter
what I read on the chart or heard
from any staff or colleagues. …
And it usually turns out that once
you approach it like that … the
situation turns out differently.”
In other words, if a physician doesn’t approach a patient
with the bias of someone else’s interpretation, that patient will not
necessarily be perceived as difficult. What about a physician’s
own biases?
PERSONAL BIASES
“A lot of a hospitalists’ interactions with patients are colored by
our own experiences,” says Bilal
Ahmed, MD, associate program
director for the residency program and associate professor of
clinical medicine, University of
Rochester School of Medicine.
For example, “when physicians
see a patient who has COPD or
cancer and is smoking,” he says,
“there may be this thought at the
back of their minds that this is
something they brought upon
themselves. [In that case] the empathy that you feel for that person may go down just a notch,
which is a very human response.”
Dr. Ahmed often discusses
remaining nonjudgmental with
his residents. “But it is not that
easy to always practice it, so it
kind of creeps back in,” he says.
In particular, biases against
obese patients are common and
have been shown to affect a physiCONTINUED ON PAGE
THE HOSPITALIST
34
> JANUARY 2007
33
BIAS IN MEDICINE > CONTINUED FROM PAGE 33
cian’s practice style. Research published in 2005 demonstrated that with regard to obese patients, poorer physical
health, a lower level of education, and a lower income level
were significantly associated with the doctor spending more
time on technical tasks during primary care medical encounters, rather than engaging in educational interactions
with these patients that encouraged health.1, 2
In a study of 62 severely overweight and 29 normal
weight adolescents, satisfaction with affective aspects of the
patient-physician relationship was negatively correlated with
body mass index score.3 And although these were studies involving primary care, a physician’s specialty is irrelevant
when it comes to these very human responses, says Howard
Beckman, MD, clinical professor of internal medicine and
family medicine at the University of Rochester School of
Medicine and Dentistry.
In the once- or twice-monthly conversations Dr.
Ahmed holds with his residents about the topic of obesity,
“we look at the social, cultural, genetic, metabolic, and other
components so we can understand that it is not just that the
person is eating a lot,” he explains. “It’s multifactorial, and
[there is] a complex set of facts that leads a person to be
where they are.”
WHAT’S BEHIND BIAS?
“The areas where we judge other people may be just the
areas where we are doing these things ourselves,” says Dr.
Beckman. “Part of why we are the way we are with certain
patients is that we fear that we may be like that person, and
we want to blame them to let ourselves off the hook.”
Many types of patients may trigger an individual physician’s dislike or aversion, including passive patients, patients
who smoke, overweight patients, depressed patients, patients
who abuse various substances, non-adherent patients, whiny
patients, passive-aggressive patients, and elderly patients.
“The movement in medicine is for insightful reflection
about what the physician brings into the room,” says Dr.
Beckman.
When he comes across a patient he does not like, Dr.
Beckman asks, “This is someone I could not like, but do I
want to not like them?” At that point, he is ready to make a
conscious decision either to change his attitude or behavior
or to seek a solution that protects patient care.
Insightfulness into the physician’s own history and
family of origin is a cornerstone of the work being done by
a number of physicians at the University of Rochester, including Dr. Beckman, an expert in physician-patient communication and the medical director for the Rochester Individual Practice Association (RIPA). For instance, was the
hospitalist’s mother overly passive or his father an alcoholic?
Dr. Beckman addressed bias recently when he rewrote
a chapter on difficult patients for a new edition of a behavioral medicine textbook.4 “One belief is that there are difficult patients; there is something about them that’s difficult,”
says Dr. Beckman. “And in some cases that may be true. But
what [investigators have now] recognized is that people who
are difficult for one doctor [may] not [be] difficult for another doctor. And so it would appear that the variable is not
the patient, but rather it’s the doctor.”
When this phenomenon was examined to a greater extent, “they tended to find that the type
of person that the doctor doesn’t like,
they’ve often seen before … usually in
their family,” he explains.
IS REFLECTION THE ANSWER?
Dr. Beckman believes it is the obligation of medical schools to help practitioners understand their own strengths
and weaknesses, including their biases. He and a number of colleagues
have just received a grant to study
teaching the practice of such mindfulness to physicians. The study will investigate whether that education will
ultimately affect a doctor’s cost of care.
Essentially, Dr. Beckman says, it
comes down to a question: Does
knowing more about yourself change
the way you practice?
At Strong Memorial Hospital in
Rochester, N.Y., where Andrew Rudmann, MD, is chief of a hospital medicine division that includes 17 faculty
members and 40 midlevel practitioners, physicians have not formally discussed having negative feelings toward
their patients. But, “I think hospitalists would do well to reflect on their
feelings about these issues,” says Dr.
Rudmann, who is also associate director of the internal medicine residency
program at Strong.
Reflection on what physicians
bring to their medical encounters
should take into account what Dr.
Beckman calls “the three big pieces” of
how humans work together in a medical encounter: “What is happening to
the patient before the doctor walks
into room, what is happening to the
doctor before he walks into the room,
and what happens in the room.” TH
Andrea Sattinger also writes about “vintage bugs” in
this issue.
REFERENCES
1. Bertakis KD, Azari R. The impact of obesity on primary care visits. Obes Res. 2005
Sep;13(9):1615-1623.
2. Robinson BE, Gjerdingen DK, Houge DR. Obesity:
a move from traditional to more patient-oriented
management. J Am Board Fam Pract. 1995 MarApr;8(2):99-108.
3. Cohen ML, Tanofsky-Kraff M, Young-Hyman D, et
al. Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative
and quantitative assessment of teen weight-related
preferences and concerns. J Adolesc Health.
2005;37:163.
4. Beckman H. Difficult Patients. In: Feldman MD,
Christensen JF, eds. Behavioral Medicine in Primary Care: A Practical Guide. New York: McGraw-Hill
Medical; 2003:23-32.
34
THE HOSPITALIST
> JANUARY 2007
A Pregnant Pause
The necessary evolution
of residency training
❚❘ By Dawn Brezina, MD
A
Rights were not granted to include this
image in electronic media. Please
refer to the printed publication.
s most of us are aware, medical education
is a long-term endeavor. Medical schools
provide students with the informational
foundation and thinking skills necessary to
be a doctor. Residency forges the knowledge into a usable skill set that builds the
final product: a clinician. Like a handthrown pot being placed in the kiln to
achieve the final step—that is, hardening with a
lustrous glaze—newly graduated medical students take
their place in residency programs to gain the experience
necessary to practice medicine. It is a system that has
worked for generations.
It has worked—but at a price. Many older physicians “put in their dues” at a cost of brutal working
hours—often exceeding 120 hours per week—with no
patient volume caps, no days off, and absolutely no regard for the resident’s home life or family. In recent
years, changes have been made in residency programs
to limit the hours worked per week and the number
of patients a physician in training is expected to
admit and cover; primarily, these changes have
been imposed on institutions to address issues of
patient safety. It may be time to take a fresh look
at residency programs and develop creative work
plans that accommodate the changing needs of
physicians and twenty-first century medicine.1
What has changed? Everything. The patients changed, the doctors changed, our society changed, and the knowledge base changed;
literally, nothing remained static. Increasing
demand for patient participation in medical
decision-making, increasing requirements for
medical documentation, and increasing demand for proof of quality performance while
concomitantly paring back the working hours
permitted per resident have stressed a rigid system to its breaking point. Creative ideas, such as
having residents admit to a single hospital floor,
are new innovations to adapt quality teaching to
the required 80-hour week.1
Additionally, in the past 25 to 30 years, medicine changed from a “man’s career” to a near gender-neutral profession. In 1970, about 7% of
physicians were women. By 1980, women accounted for 11.6% of the workforce, and in
2004, women physicians comprised more than
26% of the total.2 With medical school matriculants numbering women and men at near
parity—women have made up 45% to 49%
of medical school classes since 1999—it
is reasonable to assume that the percentage of women physicians will continue to rise annually.3 This process,
CONTINUED ON PAGE
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> JANUARY 2007
36
35
A PREGNANT PAUSE >
CONTINUED FROM PAGE
35
the feminization of medicine, has created new needs and demands that have not traditionally been identified.4
As previously noted, medical education and training
constitute a long-term process that extends into an individual’s later 20s and 30s. Deferred life issues such as marriage
and children can wait only so long, and for women the biological clock imposes an earlier time frame than the one for
men. Women often want to start a family before the end of
their residency training. The traditional residency system was
not designed to support multiple extended absences. In most
residency programs—77% of programs in one study—maternity absences are handled by requiring the other residents
to pick up the slack, an obviously less than happy arrangement.5,6 In the same survey, 83% of residency programs acknowledged that maternity leave had a significant effect on
scheduling, despite the fact that 80% of programs had a maternity policy in place.5
It is time for innovative thinking for residency training.
New plans must accommodate system needs as well as individual needs and must retain the teaching function necessary
to develop the required clinical skills. This can be done, but
it requires planning and flexibility. Most residency programs
have a maternity policy.5 This policy defines the length of
time allotted for maternity leave—free leave, or time off with
no make-up requirement. Some programs, such as the one at
the University of California at San Francisco, have incorporated a flexible option to accommodate longer absences using
flexible make-up time.7
As early as 1989 the National Health Service in the
United Kingdom proposed a part-time option in residency
training to encourage women physicians to pursue careers in
hospital medicine.8 In response to increasing numbers of
women physicians, flexible part-time specialty training programs are now generally available in the United Kingdom.9
Developing a functional part-time residency option requires planning ahead and setting aside several residency slots
to be paired as half-time equivalents. Training programs want
upfront information; they want to have some idea of how
many residents plan to start a family during residency years
so that they can anticipate the numbers needed for clinical
coverage. One would hope that open communication on this
issue would not imply discrimination in hiring and that the
information would be used to estimate the hiring needs of the
program and to accommodate shared practices.
Obviously, some residents who anticipate using the
part-time option may later choose not to have children at
that time, while others who did not plan to do so may become pregnant. Because of this variability and the inherent
concern of discrimination on the basis of the request, it is
preferable for residency programs to build in half-time residency slots based on the need experienced in prior years.
Once this program is viewed as a standard option, women
with young children—or those who anticipate pregnancy
during residency—may well request one of the part-time slots
to accommodate their needs.
Flexible—part-time—residency programs have the
downside of extending the length of training. Although most
residents do not relish the idea of a longer residency, for individuals with family commitments this is a welcome option.
The extended residency is a benefit if it allows completion of
a training program that might otherwise be impossible.
Of women physicians with children in 1988, 22% had
a child before finishing residency, and 54% had at least one
child by the time they had completed a fellowship.10 I would
guess that those percentages are significantly higher with
newer data. All residency programs with young women
physicians should anticipate pregnancy-leave time. Without
a clear plan to cover the clinical workload during these absences, one can predict anger and resentment among the residents who are expected to cover the extra work.11 If the crosscoverage plan for maternity leave is haphazard and only
created as the need arises, fellow residents tend to feel that
the burden of work is allocated capriciously. If allowed to persist, the resulting frustration damages the program’s collegiality and may result in a view of women as a risk to the best
function of the department.6 This consequence damages both
the departmental image and the status of women in medicine.
Proactive departmental planning for maternity leave
and potentially reduced work hours for women with small
children in residency training should be a priority and should
be well defined prior to the employment of new residents. Any plan needs to include options, including
a brief, fixed maternity leave and a more extended
leave with obligations for time payback or flexible extension of the residency with reduced work hours per
week. A leave plan must also include the number of
weeks a resident can be absent in a year, in two years,
and for the duration of the residency, while still fulfilling requirements for board eligibility. Likewise, to
ensure a fundamental knowledge base, rotations that
must be successfully completed should be clearly enumerated as part of the policy. As a corollary, paternity policy should also be specifically delineated.
Even residents who don’t utilize the flexible option residency like the idea that it is available if needed and believe that having a policy in place is desirable.7 Maintaining a positive espirit de corps in a
residency training program is vital to the smooth
functioning of the program and also mentors residents on the benefits of collegiality for a lifetime of
practice. Developing a well-thought-out and equitable plan for maternity, health, or family leave during residency training is as essential as figuring out
how to teach medicine to residents in an 80-hour
week—and it can be done. TH
Dr. Brezina is a hospitalist at Durham Regional Medical Hospital in
Durham, N.C., and a member of the consulting clinical faculty at Duke
University, Durham, N.C.
REFERENCES
1. Croasdale M. Redesigning Residency: new models for internal
medicine programs. American Medical News. October 23/30,
2006;Professional issues:10.
2. Smart DR. Table 1: Physicians by gender. In: Smart, DR. Physician Characteristics and Distribution in the U.S., 2006 Edition.
American Medical Association; 2006.
3. AAMC: Data Warehouse: Applicant Matriculant File by sex,
1995-2006. Association of American Medical Colleges Web site.
Available at: www.aamc.org/data/facts/2005/
2005summary.htm. Last accessed November 29, 2006.
4. Levinson W, Lurie N. When most doctors are women: what lies
ahead? Ann Intern Med. 2004 Sep 21;141(6):471-474.
5. Davis JL, Baillie S, Hodgson CS, et al. Maternity leave: existing
policies in obstetrics and gynecology residency programs. Obstet
Gynecol. 2001 Dec;98(6):1093-1098.
6. Tamburrino MB, Evans CL, Campbell NB, et al. Physician pregnancy: male and female colleagues’ attitudes. J Am Med Womens Assoc. 1992 May-Jun;47(3):82-84.
7. Kamei RK, Chen HC, Loeser H. Residency is not a race: our
ten-year experience with a flexible schedule residency training
option. Acad Med. 2004 May;79(5):447-452.
8. Warren VJ, Wakeford RE. ‘We’d like to have a family’—young
women doctors’ opinions of maternity leave and part-time training. J R Soc Med. 1989 Sep;82(9):528-531.
9. Maingay J, Goldberg I. Flexible training opportunities in the European Union. Med Educ. 1998 Sep;32(5):543-548.
10. Sinal S, Weavil P, Camp MG. Survey of women physicians on issues relating to pregnancy during a medical career. J Med Educ.
1988 Jul;63(7):531-538.
11. Finch SJ. Pregnancy during residency: a literature review. Acad
Med. 2003 Apr;78(4):418-428.
36
THE HOSPITALIST
> JANUARY 2007
ZAPPING ZINGERS
Hospitalists share the inevitable tricky questions that catch them
off guard
❚❘ By Andrea M. Sattinger
Y
ou know them, you’ve received some, and so have
your colleagues: those zinger questions—the tough
questions your patients ask that momentarily throw you
for a loop. Sometimes they’re simple, other times complex, and their psychological origin can be multifaceted.
In any case, responding to zingers requires calm, diplomacy, and tact.
“How you respond to the inevitable zingers depends in large part upon your preparation,” writes
Laura Sachs Hills in her Nov/Dec 2005 article in the
Journal of Practice Management.1 That preparation, she
suggests, is best established using staff training, group
work, brainstorming, and role-play scenarios.
Both hospitalists and primary care physicians,
writes Bernard Lo, MD, must be prepared for patients
to ask difficult questions or make unsettling comments,
even about the hospitalist system itself.2 Anticipating
the nature of those comments or questions is likely to
help the hospitalist respond in the moment.
“I don’t see these so much as zingers as challenging
or uncomfortable questions or attempts by patients to
assert some control,” says Steven Pantilat, MD, FACP,
associate professor of clinical medicine in the Department of Medicine at the University of California, San
Francisco, and past president of SHM.
Dr. Pantilat believes that the term “zinger” can
imply they are used with malicious intent, yet, he comments, “I’m not sure they are, even if they are an attempt to exert control or challenge the physician. I suspect they arise from fear or other responses.” Below,
some of the zingers Dr. Pantilat has dealt with.
How long have you been a doctor? “I’ve now
been one long enough not to be flustered by this question, but many hospitalists are young and may be taken
aback,” says Dr. Pantilat. “It’s a challenge to the doctor’s authority and expertise.”
Doc, you look so young is a related comment,
believes Dr. Pantilat—one that can be interpreted as a
compliment or a zinger. “My standard response is always, ‘I’m old enough to take that as a compliment,’ ”
he says. “These days I really mean it.”
Vineet Aurora, MD, hospitalist at the University of
Chicago Medical Center, says she is sometimes asked,
“How old are you?”
“I think it happens to a lot of women who are or
look young,” she says. “I usually just state my age,
[which is] 32. Often they will say, ‘Oh you look much
CONTINUED ON PAGE
Rights were not granted to include this
image in electronic media. Please
refer to the printed publication.
52
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> JANUARY 2007
37
DEJA VU
Old bugs wreak havoc with
patients once again
❚❘ By Andrea M. Sattinger
W
e thought they were gone, but they’ve returned: diseases once considered “vintage bugs” that were common in as late as the mid-20th century. In the past
these diseases killed one in three people younger
than 20 who had survived an infancy during which many of their
contemporaries died.1
“When you think about disease states, you think about some
that are gone from the world,” says Erin Stucky, MD, a pediatric hospitalist at the University of California, San Diego, “but there are very
few truly gone from the world.”
Some of the major infectious diseases that hospitalists may [still]
see are pertussis (whooping cough), measles, and mumps, but scarlet
fever and varicella (chicken pox) also endure—not to mention those
occurrences of polio around the country that epidemiologists and infectious diseases specialists are monitoring closely. Rickets, a vitaminD-deficiency-related disease also thought to be a relic of the 18th century, is showing up in certain patient populations—and not
exclusively in infants and children.
This is a crossover clinical issue, our pediatric hospitalists say,
and thus one to which their hospitalist partners who treat adult patients must also remain alert.
PERTUSSIS (WHOOPING COUGH)
ALL PHOTOS COURTESY CDC
> This negative stained transmission electron micrograph (TEM) depicts the ultrastructural features displayed
by the mumps virus.
Despite vaccination protocols, pediatric hospitalists continue to see
whooping cough in young infants. (See Figure 1, p. 39.) Even with
treatment, the damage can be severe, and the length of stay (LOS) is
prolonged compared with those of most other patients with complex
illnesses. “Vaccine fatigue” means that immunization lasts only until
adolescence or early adulthood, at which time they need appropriate
boosters. If the patient hasn’t receive boosters, the initial immunization loses its effectiveness; unprotected, they can be infected with the
disease, though sometimes not badly enough for them to seek care.
When they do, the diagnosis is often community-acquired mild pneumonia or a more traditional bronchitis. Either by accident or because
the physician has given it thought, those illnesses are treated with a
macrolide drug, which is also—coincidentally and serendipitously—
the drug of choice for pertussis. But many remain carriers because
they are not accurately diagnosed or never seek care.
> A photomicrograph of Bordetella (Haemophilus) pertussis bacteria
> This thin-section transmission electron micrograph (TEM) reveals the ultrastructural appearance of a single
virus particle, or “virion,” of measles virus.
38
THE HOSPITALIST
> JANUARY 2007
using the Gram stain technique. Bordetella is a highly communicable,
vaccine-preventable disease that lasts for many weeks and is typically
manifested in children with paroxysmal spasms of severe coughing,
whooping, and post-tussive vomiting (also known as Bordet-Gengou
bacillus).
70
Pneumonia
60
Hospitalization
PERCENT
50
40
30
20
10
ye
ar
s
>
19
to
to
10
5
20
ye
ar
s
ye
ar
s
9
ye
ar
s
4
to
6
1
to
<
11
6
m
on
th
s
m
on
th
s
0
AGE GROUP
Figure 1. Number of reported pertussis cases by age group in the United States in 2003.
Adapted from Hopkins RS, Jajosky RA, Hall PA, et al. Centers for Disease Control and Prevention.
Summary of notifiable diseases—United States, 2003. MMWR. 2005;52:55. Source: Gregory DS.
Pertussis: a disease affecting all ages. Am Fam Physician. 2006 Aug 1;74(3):420-426.
18
INCIDENCE
“There is a huge reservoir of people carrying pertussis, particularly [in] the adolescent and adult population[s],” says Alison Holmes,
MD, a pediatric hospitalist at Concord Hospital, N.H. “And the babies who get really sick from it are the under two- to three-month
group who have not yet been immunized or have just been immunized. Because it is so rampant in the adolescent and adult community, those children can still get sick.”
“Unfortunately,” says Dr. Stucky, “what’s happening is that if
physicians are not thinking pertussis, they don’t talk about pertussis
to that adult patient who … is either around children or has children
in the home. So they don’t know to tell that person to watch for these
same signs and symptoms in that young infant, who then could have
a much more severe outcome from getting [the infection].”
As with most patients who contract illnesses, these patients may
never have heard of the disease and unless educated may not understand the implications of the diagnosis. They might realize their disease could spread to family members, “but most people don’t absorb
that information and use that information thoughtfully,” says Dr.
Stucky. The onus is, therefore, on the physician to warn adult patients specifically about the serious danger that exists for infants in
the two- to three-month-old group, who may not have been vaccinated or whose single-vaccination immunity is not adequate protection against the disease.
While the numbers in babies appear to be what they have always
been, the incidence has grown in the teen years and even later into
adulthood. This is more likely the result of increased testing for pertussis, as opposed to being only due to a true resurgence. Data from
studies of adults with prolonged cough revealed that 20% to 25%
have serologic evidence of recent pertussis infection.2 Adults are the
major reservoir of infection, and infection spreads quickly in a population in a closed environment where droplets spread easily person
to person.5
For both teens and adults, testing and immunization with the
newly recommended DTaP (diphtheria-tetanus-pertussis)—as opposed to the more limited Td—can help upgrade immunity. Although a patient can recover from pertussis on his or her own within one to two weeks following treatment, the intent of treatment is
primarily to limit the spread of disease to others.4-7
The problem when adults get pertussis, says Dr. Holmes, who is
also an assistant professor of community and family medicine at Dartmouth Medical School, Hanover, N.H., “is that they often don’t show
up complaining about this horrible paroxysmal coughing until they’re
about three or four weeks into the illness, and it hasn’t gone away.
You go for hours and hours feeling completely fine and wonderful,
and why would you bother going to the doctor?”
Babies are most at risk, however. “They often don’t have the
energy or the muscle strength, so they just stop breathing instead,”
she says.
Mark Dworkin, MD, MPH, TM, the state epidemiologist and
team leader for the Rapid Response Team at the Illinois Department
of Public Health, is active in outbreak investigation. He wrote a compelling argument for maintaining a high index of suspicion when
physicians see adolescent and adult patients who have a cough that
has lasted more than two weeks.4
It has been estimated that more than one million cases of pertussis occur in the United States each year; that number has continued to grow for 20 years. From 1990 to 2001, the incidence of pertussis in adults increased by 400%. But many physicians believe that
pertussis is only a pediatric illness. A survey of internists in Washington state showed that only 38% of respondents knew about the risk
of vaccine fatigue, and just 36% knew that the nasopharyngeal swab
is the preferred method for sample collection. Public health professionals were also concerned with the finding that too many pediatricians and nonpediatricians (43% and 41%, respectively) were not
able to define a reportable case.
The first challenge that faces internists, writes Dr. Dworkin, is recognizing pertussis, which in some cases presents with mild symptoms;
some adults won’t even have a cough.4 But at the other end of the disease spectrum, symptoms may be as brutal as bilateral subconjunctival
hemorrhage or rib fracture due to convulsive coughing. In any case, what
goes unrecognized, undiagnosed, and untreated becomes a particularly
serious risk for vulnerable infants. Once pertussis is identified, positive
results on polymerase chain reaction or culture can help convince skeptical colleagues who may still believe pertussis is exclusively a childhood
disease—and a vintage one at that.
“What we in pediatrics champion … is for [these immunizations] to help the young child; the less disease we have out there, the
better off we’re going to eventually be,” says Dr. Stucky, who projects
that, within just a few years, Tdap vaccinations for adolescents and
adults up to age 64 might lead to a reduction of infection in the threemonth-old group.6
12
6
0
<1
18-24
5-17
1-4
25-39
40-59
> 60
AGE GROUP (years)
* Per 100,000 population (n= 2,061)
Iowa, Illinois, Kansas, Missouri, Nebraska, Pennsylvania, South Dakota, Wisconsin
Figure 2. Incidence* of mumps reported in eight outbreak states, by age group — U.S., Jan. 1May, 2 2006. Source: Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and
pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR
Recomm Rep. 2006;55:1-34.
800
700
600
500
400
300
200
100
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
* Provisional number of cases (N= 5,783) as reported to the National Notifiable Diseases Surveillance System.
Figure 3. Number of mumps cases,* by month of onset — U.S., January 1-October 7, 2006
Source: MMWR. Brief report: update: mumps activity—United States, January 1-October 7, 2006.
MMWR. 2006;55:1152-1153.
MEASLES AND MUMPS
From January 1 to October 7, 2006, 45 states and the District of Columbia reported 5,783 confirmed or probable mumps cases to the Centers for Disease Control and Prevention (CDC). (See Figures 2 and 3,
above.)8 The Advisory Committee on Immunization Practices (ACIP)
announced that continuing data from surveillance reports meant that
healthcare workers should remain alert to suspected cases, conduct appropriate laboratory testing, and use every opportunity to ensure adequate immunity, particularly among populations at high risk.7
In contrast to the circumstances with pertussis, with mumps “there
have been pockets of people who have either chosen not to immunize
their child[ren], or their child[ren] get exposed to it somehow,” says Dr.
Stucky, “and although they might be immunized, they might not have
had a good response.” In an environment such as a school, “where one
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> JANUARY 2007
39
DEJA VU >
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39
PEDIATRICIANS SUPPLEMENTING (%)
80
Before
1970s
60
1970s
1990s
1980s
40
20
0
A
GRADUATION FROM MEDICAL SCHOOL
PEDIATRICIANS (%)
40
VARICELLA (CHICKEN POX)
30
20
10
0
B
0
0-1
2
4
6
>6
RECOMMENDED AGE FOR INITIATION OF
SUPPLEMENTATION (MONTHS)
Figures 4A and 4B. Percentage of pediatrician practices for breast-fed infants, grouped
by decade(s) of graduation from medical school. Source: Davenport ML, Uckun A, Calikoglu AS.
Pediatrician patterns of prescribing vitamin supplementation for infants: do they contribute to rickets? Pediatrics. 2004 Jan;113(1):179-180.
A: Recommending vitamins for none (black bar), some (gray bar), or all (white bar) infants.
Note the high percentage of pediatricians who graduated before 1970 and who recommend vitamins for all breast-fed infants in comparison to those who graduated more recently.
B: Recommended age at initiation (in months). Graduation from medical school before
1990 (white bar) and in the 1990s (black bar) are shown. Note that those who graduated in the
1990s recommend that vitamins be initiated at later ages.
child can cough on a few and then cough on a few [more],” there is an
environment where the infection can spread rampantly.
With mumps and measles, these could be called true outbreaks,
such as the classic example that occurred in Kansas 18 years ago or
the epidemic that disseminated from a college campus in Iowa in
the spring of 2006, which originated from only two airline passengers on nine different flights within one week.8
College dorms and cafeterias can be treacherous breeding
grounds for pathogens, and this generation of college students is susceptible for a few reasons. For one, in the late 1980s, when they were
infants, the vaccine schedule was changed; the measles/mumps/
rubella vaccine was upgraded from one dose to two—and not all
children received the two doses.
The unimmunized who are exposed to measles and mumps remain at highest risk for spreading the disease. Although in 2005,
76%-79% of children aged 19-35 months received the entire recommended series of shots against whooping cough, diphtheria,
tetanus, polio, measles, mumps, rubella, chicken pox, hepatitis B,
and Haemophilus influenza type B, that still means that 21%-24%
of the children—or potentially one out of five kids—did not.9
Other factors causing low levels of immunization include parents’ Internet-fueled fears of links to autism; immigrants crossing
U.S. borders from Mexico or other countries where immunization is
not standardized; religious and philosophical reasons; and international travel.10
“When young adults travel internationally [to places] where
they are exposed to young children and adults who have never been
immunized,” that’s a big risk, says Dr. Stucky. “All it would take is
one [infected] student coming into a dorm and passing it around [to
others with lapsed coverage or no immunization for the disease].”
And while providers may think of travelers being exposed to diseases
such as malaria and typhoid fever in developing countries, “in reality, a lot of the common things we’re immunizing for in our country are not immunized for in other countries, and those can be
brought back.”
RICKETS
The incidence of rickets is increasing, especially in black and Hispanic children and particularly in the north.11,12 Epidemiologists trace
the rise to an increase in breast-feeding (good for immunity, but
40
THE HOSPITALIST
> JANUARY 2007
breast milk lacks substantial vitamin D), overuse of sunscreen or lack
of exposure to sunlight, and changes in physician recommendations
for vitamin supplementation. The effects of rickets alone can be profound, but other long-term consequences of vitamin D deficiency
may include type I diabetes, cancer (especially of the prostate), and
osteoporosis.12
In the past few decades, physicians have been less likely to recommend vitamin D supplementation for babies, and an interesting
study by Davenport and colleagues correlates the year of medical
school completion to that decline as well as substantial variability as
to the age at which supplement use is begun.12 (See Figures 4a and
4b, left.)
“Most of the cases I have run into have been in [recent] African
immigrants, where the mothers stay covered and they are vitamin D
deficient,” says Dr. Holmes. “It’s wonderful that they culturally
breast-feed, but they come to the U.S., and they’re pretty afraid to go
outside in a new society.”
Varicella was removed from the CDC’s national notifiable disease
list in 1981, but in 1995 a varicella vaccine was recommended for
routine childhood vaccination.13 Before the licensure of that vaccine,
varicella was a universal childhood disease in the U.S., causing 4 million cases, 11,000 hospitalizations, and 100 deaths every year.14 In
2002, the Council of State and Territorial Epidemiologists recommended that varicella be included in the National Notifiable Surveillance System by 2003 and that case-based surveillance in all states
be established by 2005.13 CDC’s ACIP recommended in 2006 that
a routine second dose of varicella vaccine be given to children between the ages of four and six years old.
Contracting chicken pox as an adult is a much more morbid
occurrence than catching it as a child. Although varicella is not life
threatening (as are diphtheria, tetanus, and measles) or sterility-causing (as is mumps), when the vaccine was approved, some pediatricians, including Dr. Stucky, became concerned that “now we’re creating a population that has never seen the wild-type varicella virus,
and what does that mean? Were we just delaying something into an
age category where people will get sicker?” Recognizing varicella,
therefore, is critical even for hospitalists who treat adults.
CONCLUSION
“I’ve seen mumps, measles, varicella, pertussis,” says Dr. Stucky, “but
our adult [hospitalist] partners hadn’t.” She encourages her colleagues
who treat adult populations “to read and be diligent. These diseases
can exist in adults, or even in children who were once vaccinated,
and all hospitalists need to know “what to do, how to treat them,
and [that] the consequences in adults are hands down worse than in
children.”
Dr. Stucky believes hospitalists who treat adults would do well
to consult physicians who practiced in the 1950s because they understand the history as well as clinical signs and symptoms of these
diseases; she says, “For the hospitalist who treats adults, these are the
equivalent of emerging infectious diseases.” TH
Andrea Sattinger is a frequent contributor to The Hospitalist.
REFERENCES
1. Carmichael M. 'Vintage' bugs return. Newsweek. May 1, 2006:Vol. 147, p. 38. Available
at: www.msnbc.msn.com/id/12440796/site/newsweek/. Accessed on November 29,
2006.
2. Herwaldt LA. Pertussis in adults. What physicians need to know. Arch Intern Med.
1991;151:1510-1512.
3. Schafer S, Gillette H, Hedberg K, et al. A community-wide pertussis outbreak: an argument
for universal booster vaccination. Arch Intern Med. 2006 Jun 26;166(12):1317-1321.
4. Dworkin MS. Adults are whooping, but are internists listening? Ann Intern Med. 2005 May
17;142(10):832-835. Available at: www.annals.org/cgi/reprint/142/10/832.pdf. Accessed on November 19, 2006.
5. Gregory DS. Pertussis: a disease affecting all ages. Am Fam Physician. 2006 Aug
1;74(3):420-426.
6. Finger R, Shoemaker J. Preventing pertussis in infants by vaccinating adults. Am Fam
Physician. 2006 Aug 1;74(3):382.
7. Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis
among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis
vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR Recomm Rep. 2006;55:1-34.
8. MMWR. Brief report: update: mumps activity—United States, January 1-October 7, 2006.
MMWR. 2006 Oct 27;55(42):1152-1153.
9. National Briefing: Science and health: race gap closes in vaccinations, U.S. says. New York
Times. September 15, 2006.
10. Calandrillo SP. Vanishing vaccinations: why are so many Americans opting out of vaccinating their children? Univ Mich J Law Reform. 2004 Winter;37(2):353-440.
11. Kreiter SR, Schwartz RP, Kirkman HN Jr, et al. Nutritional rickets in African American
breast-fed infants. J Pediatr. 2000 Aug;137(2):153-157.
12. Davenport ML, Uckun A, Calikoglu AS. Pediatrician patterns of prescribing vitamin supplementation for infants: do they contribute to rickets? Pediatrics. 2004 Jan;113(1 Pt 1):179180.
13. MMWR. Varicella surveillance practices—United States, 2004. MMWR. 2006 Oct
19;55:1126-1129.
14. Seward JF, Watson BM, Peterson CL, et al. Varicella disease after introduction of varicella
vaccine in the United States, 1995-2000. JAMA. 2002 Feb 6;287(5):606-611.
>
Atrial Flutter, Endarterectomy Versus Stenting, Care
Transitions, Pleural Empyema, RRS Consensus, Treating VTE
Patients, Classic Lit on Beta Blockers, and ACE Inhibitors
❚❘ By Katherina Tillan-Martinez, MD; Preethi Patel, MD; Vesselin Dimov, MD; Vaishali Singh, MD, MBA, MPH;
Brian Harte, MD—all from the Section of Hospital Medicine, Cleveland Clinic
IN THE LITERATURE
Treat Atrial Flutter
Da Costa A, Thévenin J, Roche F, et al. Results from the Loire-ArdècheDrôme-Isère-Puy-de-Dôme (LADIP) trial on atrial flutter, a multicentric
prospective randomized study comparing amiodarone and radiofrequency
ablation after the first episode of symptomatic atrial flutter. Circulation.
2006;114:1676-1681.
Radiofrequency ablation (RFA) has high success rates in atrial flutter, and American College of Cardiology/American Hospital Association
guidelines classify a first episode of well-tolerated atrial flutter as a class
IIa indication for RFA treatment. The LADIP trial compared RFA with
the current practice of electroosmotic flow (EOF) cardioversion plus
amiodarone after a first episode of symptomatic atrial flutter.
One hundred and four consecutive patients with a documented first episode of atrial flutter were enrolled over a period of 39
months. Excluded from the study were patients under the age of
70, those who had had previous antiarrythmic treatment for atrial
flutter, those who had an amiodarone contraindication, patients
with New York Heart Association class IV heart failure, and those
who had a history of heart block. All 52 patients in group I received
RFA by a standard method. Fifty-one of the 52 patients in group II
underwent intracardiac stimulation, followed, if necessary, by external or internal cardioversion. All patients in group II received
amiodarone as well as vitamin K antagonists.
The patients were followed up in the outpatient department at
setting. Because RFA is an invasive procedure, it is user-dependent and
may be unfeasible in different care settings. Also, RFA might not be as
appropriate for many symptomatic patients with atrial flutter and hemodynamic instability. Nevertheless, this study presents hospital-based
physicians with an additional consideration in the acute care setting for
patients with a first episode of atrial flutter.
A Transitional Care Intervention Trial
Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention:
results of a randomized controlled trial. Arch Intern Med. 2006;166:18221828.
A growing body of evidence suggests that the quality of health
management decreases when patients are transitioned across sites of
care—particularly when they are not adequately prepared to self-manage their chronic disease, when they receive conflicting advice from various providers, or when they do not have access to their healthcare
providers. Higher rates of medication errors and lack of appropriate follow up compromise patient safety during this vulnerable period. This is
a particular problem for hospitalists, who introduce an additional discontinuity into the flow of patient care. Because patients and their caregivers are the only common thread moving across various sites of care,
this study targeted them for an intervention designed to improve the
quality of transitional care.
The study was done in collaboration with a not-for-profit capitated system in Colorado. To be eligible for the study,
patients had to be over age 65 and admitted to one
of the participating hospitals. Patients had to be
This study is the largest to date showing the
community dwelling with no documented demensuperiority of RFA to cardioversion plus
tia and had to have one of eleven diagnoses selected
to reflect a higher likelihood of long-term subacute
amiodarone after the first episode of
care or anticoagulation, including stroke, congestive
symptomatic atrial flutter.
heart failure, COPD, diabetes, hip fracture, coronary artery disease, and pulmonary embolism. The
intervention group comprised 379 patients, while
one, three, six, 12, and 18 months after randomization and at the end the control group was made up of 371 patients.
of the study. At each visit, arrhythmic or cardiovascular events were
The intervention model was built on four pillars derived from prior
recorded, and a 12-lead ECG was obtained. Patients were fitted with a qualitative studies about care transitions:
Holter monitor for seven days if they had recurring palpitations or
1. Assistance with medication self-management;
symptoms. The primary outcome studied was recurrence of sympto2. A healthcare record owned and maintained by the patient;
matic atrial flutter and occurrence of atrial fibrillation.
3. Timely physician follow-up; and
After a mean follow-up of 13+/-6 months, atrial flutter recurred in
4. A list of red flags indicative of clinical deterioration.
two of the 52 (3.8%) patients in group I and 15 of 51 (29.5%) patients
Intervention-group patients had access to a personal health record
in group II (P<0.0001). In group I, one patient required a second, suc- that included an active problem list, medications, allergies, and a list of
cessful ablation. All the patients who recurred in group II were success- red flags; in addition, these patients received a series of visits and telefully treated using RFA. The occurrence of significant symptomatic atri- phone calls with a “transition coach,” an advanced care nurse who enal fibrillation was 8% in both groups at the end of the first year. By the couraged self-care by patients and their caregivers, facilitated commuend of the study, two patients in group I and one patient in group II nication between providers and patients, and assisted in medication
were in chronic atrial fibrillation. When all the episodes of atrial fibril- review and reconciliation.
lation were counted (including those patients whose episodes lasted <10
The primary outcome measure was the rate of nonelective rehosminutes but were documented with an event monitor), the groups did pitalization at 30, 90, and 180 days after discharge from the index hosnot differ significantly.
pitalization. Ninety-five percent of the intervention patients and 94.9%
No procedure-related complications occurred in group I. In the of the control subjects were included in the analysis. Intervention paamiodarone group, however, two patients developed hypothyroidism, tients had lower adjusted hospital readmission rates than controls at 30
one developed hyperthyroidism, and two patients had symptomatic sick (8.3% versus 11.9%) and 90 days (16.7% versus 22.5%), P=0.048 and
sinus syndrome. There were a total of 14 deaths during the course of the 0.04 respectively. The result did not achieve significance at 180 days
study (six patients in group I and eight patients in group II); none were after discharge (P=0.28). Rehospitalization for the same diagnosis as the
related to the study protocol.
index diagnosis within 90 and 180 days of admission was 5.3% in the
This study is the largest to date showing the superiority of RFA to intervention group versus 9.8% in the control group (P=0.04) and 8.6%
cardioversion plus amiodarone after the first episode of symptomatic in the intervention group versus 13.9% (P=0.045) in the control group,
atrial flutter. The long-term risk of subsequent atrial fibrillation was respectively, but did not meet statistical significance within 30 days of
found to be similar to that of the amiodarone-treatment group. Because readmission.
the mean age of patients in this study was 78, however, these findings
The concepts of a transition coach and a patient-maintained record
cannot necessarily be extrapolated to younger patient populations. Fur- are enticing, considering the amount of time hospitalists may invest in
ther, oral amiodarone was used initially in this study. It can be argued patient education and discharge planning processes. This study is difthat IV amiodarone is far more efficacious than oral forms in the acute
CONTINUED ON PAGE 42
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41
IN THE LITERATURE > CONTINUED FROM PAGE 41
ferent from prior studies in that it used transition coaches instead of healthcare professionals to assume the primary role
in managing the post-hospitalization course, and it provided the caregiver and patient with tools that could be applied
to future care transitions. The costs of intervention in this
study were found to be about $74,310 for the transition
coach and other related costs, compared with a semi-annual cost savings of $147,797.
The main drawbacks of the study were that the 180day all-cause readmission rates did not achieve statistical significance, and even though the adjusted P values for allcause 30- and 90-day readmission rates were reported to
be significant, their 95% confidence interval for the odds
ratio barely meets appropriate analytical criteria (OR 0.59
[0.35-1.00] and 0.64 [0.42-0.99]). Also disappointing
was the fact that there was no difference in readmission
rates at 30 days for the index diagnosis. Therefore, healthcare systems would likely hesitate to implement these interventions without more
definitive data showing reductions in adverse outcomes and mortality rates.
Pleural
Empyema
in CAP Cases
Ahmed RA, Marrie TJ,
Huang JQ. Thoracic empyema in patients with community-acquired pneumonia.
Am J Med. 2006
Oct;119(10):877-883.
Pleural effusions complicate up to 44% of cases of
community-acquired pneumonia (CAP). Of these
cases, 10% develop complicated parapneumonic effusions. In the past, pleural
empyema has been associated with poor outcomes and
high mortality rate. Unfortunately, most of these studies were performed before
the advent of newer antimicrobial agents and more
modern diagnostic and therapeutic techniques.
This prospective, population-based study included all patients older than 17
who had been admitted
with a diagnosis of CAP.
Most of these patients were
diagnosed and managed according to a “Pneumonia
Critical Pathway.” Adherence to any aspect of the
pathway by the admitting
physician was completely
voluntary.
Of 3,675 patients enrolled in the study, 47
(1.3%) were diagnosed with
empyema by the attending
physician—a number which
correlates with previous
studies. Of these, only 24
(0.7%) were ultimately classified as “definite empyema”
by one or more of the following criteria:
1. Presence of microorganisms on Gram
stain or culture of
the pleural fluid;
2. Pleural fluid with a
pH <7.2 plus radiographic evidence
suggesting empye42
THE HOSPITALIST
> JANUARY 2007
ma; and
3. Frank pus in the pleural space at time of thoracoscopy.
The remaining 23 (0.6%) patients were classified as
suspected empyema.
The study then compared the patients without empyema with patients with definite empyema. Patients with definite empyema were younger, more likely to have received
antibiotics before admission, and more likely to have been
admitted to the ICU. Further, these patients had a higher incidence of illicit drug use and frequently presented with a
history of systemic symptoms, including fevers, chills, and
pleuritic chest pain. Laboratory studies—aside from elevated WBC—were not useful in distinguishing between the
two groups. Also, there were no significant features on chest
radiographs to separate the two groups, although in patients
with complex fluid collections, 19 of 22 patients (86%) with
definite empyema had computed tomography (CT) scans
suggesting the diagnosis.
Streptococcus milleri was the most common pathogen,
isolated in 50% of patients with definite empyema. Patients
with definite empyema were more likely to have invasive diagnostic procedures and had longer hospital stays (23.5 +/17 days) compared with their CAP counterparts (12.4 +/20.2 days, P=0.007).
Clinical and laboratory features remain nonspecific and
should be used with caution when differentiating between
empyema and complicated pleural effusions. Diagnostic
pleural effusion aspiration is essential if infection is suspected. This study also points out the greater need of ICU support in definite empyema cases that suggest a greater severity of illness.
Interestingly, definite empyema had an in-hospital
mortality rate of 4.2%, compared with 10% for CAP
(P<0.05). Possible reasons for this result included the fact
that 50% of the empyema cases were suspected at admis-
sion and thereby received earlier antibiotic treatment and
more aggressive management than CAP cases.
Rapid Response Systems:
A Call for Research
Devita MA, Bellomo R, Hillman K, et al. Findings of the first
consensus conference on medical emergency teams. Crit Care
Med. 2006 Sep;34(9):2463-2478.
The Institute for Healthcare Improvement has endorsed the concept of Rapid Response Teams (RRTs), and
the 2005-2006 SHM survey indicated that 35% of responding hospitalist groups were involved with such systems. The field of in-house medical emergency teams suffers
from a lack of quality research, however. Most of the existing data come from single-institution studies, and analysis is
limited by a lack of standard definitions or processes. This
consensus document addresses these issues and offers a “state
of the literature” in RRTs, or—as the authors redefine
them—rapid response systems, and attempts to frame the
research agenda going forward.
The authors define an in-hospital medical emergency
as a “mismatch between patient needs and resources available” and then proceed to outline the various types of responses that have been described, including medical emergency teams (METs), RRTs, and critical care outreach teams
(CCO). According to the authors, a MET generally brings
ICU capabilities, including procedures and medications, to
the bedside, whereas an RRT is a “ramp-up” response, sometimes led by a nurse, that can rapidly assess and triage patients to a higher level of care. To be part of a complete RRS,
any of these response options needs to have an adequate detection/triggering arm (“afferent”), a response arm (“efferent”), and administrative and QI components.
After establishing their suggestions for standardized
nomenclature and the necessary components of a rapid response system (RRS), the authors review the literature and
make several recommendations regarding areas for future research. In particular, they note that there is no data to
demonstrate that one set of triggering criteria is superior to
another to identify patients who will benefit from an RRS
intervention; nor is there adequate literature on the relative
effectiveness of the different types of responses. Finally, the
authors make a formal recommendation that hospitals implement both afferent and efferent systems, although, interestingly, they do so based on evidence from single-center,
historical-control trials and in spite of the lack of benefit seen
in the only published multicenter randomized controlled
trial (MERIT).
The authors also describe RRS as potentially inexpensive, but offer no data to support this claim. In fact, the
prospect of dedicated 24-hour response personnel is probaCONTINUED ON PAGE
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IN THE LITERATURE > CONTINUED FROM PAGE 43
bly more daunting for most institutions than the authors
acknowledge. In any case, this is excellent reading for hospitalists, who will continue to be key players in the evolution
of these systems, and the report is also accompanied by an
outstanding bibliography.
Symptomatic Severe Carotid
Stenosis: Endarterectomy
Versus Stenting
Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus
stenting in patients with symptomatic severe carotid stenosis. N
Engl J Med. 2006;355(16):1660-1671.
Two large, randomized, clinical trials have established
endarterectomy as the standard treatment for severe symptomatic carotid artery stenosis. The new method of carotid
44
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stenting avoids the need for general anesthesia and may cost
less than surgery, but it is unclear if stenting is as effective as
or safer than endarterectomy.
The authors conducted a publicly funded, randomized
controlled trial in 20 academic and 10 nonacademic centers in France to compare stenting with endarterectomy in
patients with symptomatic carotid stenosis. Patients were
eligible if they were 18 years of age or older, had had a
hemispheric or retinal transient ischemic attack or a
nondisabling stroke within 120 days of enrollment, and
had a stenosis of 60% to 99% in the symptomatic carotid
artery.
Patients were excluded if one of the following was
present: a modified Rankin score of three or more (disabling stroke); nonatherosclerotic carotid disease; severe
tandem lesions (stenosis of proximal common carotid artery or intracranial artery that was more severe than the
cervical lesion); previous revascularization of the sympto-
matic stenosis; a history of bleeding disorder; uncontrolled hypertension or diabetes; unstable angina; contraindication to heparin, ticlopidine, or clopidogrel; life
expectancy of less than two years; or percutaneous or surgical intervention within 30 days before or after the study
procedure. The primary endpoint was the incidence of
any stroke or death within 30 days after treatment.
The trial (EVA-3S) was stopped early, after the inclusion of 527 patients, for reasons of both safety and futility. The 30-day risk of any stroke or death was significantly higher after stenting (9.6%) than after
endarterectomy (3.9%), resulting in a relative risk of 2.5
(95% CI, 1.2 to 5.1). The 30-day incidence of disabling
stroke or death was 1.5% after endarterectomy (95% CI,
0.5 to 4.2) and 3.4% after stenting (95% CI, 1.7 to 6.7); the
relative risk was 2.2 (95% CI, 0.7 to 7.2). At six months, the
incidence of any stroke or death was 6.1% after endarterectomy and 11.7% after stenting (P=0.02). Cranial nerve in-
jury was more common after endarterectomy than after
stenting.
The practice of interventional physicians has expanded in the last few years to include placement of stents—not
only in coronary arteries but also in carotid arteries and other
vessels. As hospitalists, we must be aware of the latest research in this changing field to provide the best evidencebased advice to our patients.
Currently, the only use of carotid stenting that has
been approved by the Food and Drug Administration
(FDA) is in symptomatic patients with carotid artery
stenosis of 70% or more who are at high surgical risk. This
FDA approval is based on the results of the Stenting and
Angioplasty with Protection in Patients at High Risk for
Endarterectomy (SAPPHIRE) study, which included
symptomatic patients with carotid artery stenosis exceeding 50% and asymptomatic patients, with stenosis exceeding 80%, who were at high surgical risk mainly due
to severe coronary artery disease. The SAPPHIRE study
showed that stenting was safer than endarterectomy mainly due to lower risk of myocardial infarction within 30
days after carotid stenting as compared with surgery.
There was no significant difference in the rates of stroke
or death between stenting and endarterectomy.
Why does the EVA-3S trial reported in NEJM show
opposing results? The patients in the trial were different
than the ones included in the SAPPHIRE study, and the
periprocedural protocol was less strict. The patients in the
EVA-3S trial were not at high surgical risk. Further, all
patients in the EVA-3S trial had symptomatic carotid artery stenosis, whereas the majority of patients in the SAPPHIRE study were asymptomatic. Use of aspirin and
clopidogrel or ticlopidine three days before carotid-artery
stenting was only recommended in the EVA-3S trial but
was required in the SAPPHIRE trial.
The ongoing Carotid Revascularization Endarterec-
tomy versus Stenting Trial (CREST), funded by the National Institutes of Health, is enrolling patients with an
average surgical risk similar to those in the EVA-3S study.
The CREST study, which is expected to enroll 2,500 patients, may be able to provide a more definitive answer regarding the best treatment for symptomatic patients with
high-grade carotid stenosis with an average surgical risk.
In the meantime, what should we recommend to our
patients? For symptomatic patients with carotid artery
stenosis of 70% or more, endarterectomy is superior to
medical therapy alone. For asymptomatic patients with
carotid artery stenosis exceeding 60%, endarterectomy is
also superior to medical therapy alone, assuming a risk of
perioperative stroke or death of less than 3%. Currently,
the only accepted indication for stenting is in symptomatic patients with carotid artery stenosis exceeding 70%
and a high surgical risk.
D-Dimer
Testing to
Risk Stratify
VTE Patients
Palareti G, Cosmi B, Legnani C, et al. D-dimer testing to determine the duration of anticoagulation
therapy. N Engl J Med.
2006;355:1780-1789.
D-dimer levels have
been used to assist in diagnosing initial episodes
of venous thromboembolism (VTE). Although
not specific, D-dimer testing is very sensitive for
VTE, giving it a high negative predictive value.
Further, duplex ultrasound often remains abnormal after VTE, making the distinction
between recurrent disease
and old disease problematic when symptoms
recur.
A recent study by
Rathbun and colleagues
investigated the use of Ddimer measurement in excluding recurrent VTE,
finding that of former
VTE patients presenting
with symptoms, only
0.75% with a negative Ddimer level had recurrent
VTE on ultrasound, compared to 6.0% with a positive test who had recurrent VTE. This study,
conducted by Palareti and
colleagues, tries to go a
step further and assess
whether D-dimer testing
can be used to risk stratify
VTE patients who are
asymptomatic following
treatment for an initial
episode of VTE, as well as
whether or not it can be
used to determine the
need to continue anticoagulation.
The PROLONG
study was a multicenter
prospective study of patients between 18 and 85
who had had their first
episode of unprovoked,
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IN THE LITERATURE > CONTINUED FROM PAGE 45
symptomatic VTE (including pulmonary embolism). Patients were enrolled in this study after completing treatment with vitamin K antagonists (VKA) for at least three months with a target INR (international
normalized ratio) in the range of 2-3. Exclusion criteria included severe
liver insufficiency, renal insufficiency with serum creatinine >2, or clear
indications/contraindications for anticoagulation.
Six hundred twenty-four patients treated for VTE were enrolled in
the study. All underwent compressive ultrasound in both legs to establish a baseline at the start of the study and were then instructed to stop
anticoagulation. Follow-up occurred in one month, with another ultrasound to assess recurrence of VTE. Five patients were found to have
VTE and were excluded. The remaining 619 patients were tested for Ddimer levels and were given thrombophilia tests. A further 11 patients
were excluded due to antiphospholipid antibodies or antithrombin deficiency. Patients with factor V Leidin and G20210A mutation on the
prothrombin gene were allowed to participate in the study.
Three hundred and eighty-five patients had normal D-dimer levels and were not placed on anticoagulation. The 223 patients with abnormal D-dimer levels were randomized to receive VKA (103 patients)
or no treatment (120 patients). All patients were followed for minimum
of 18 months. Of the 120 patients with abnormal D-dimer levels who
were randomized to no treatment, 18 patients (15.0%) had recurrent
VTE. Of the 103 patients with abnormal D-dimer levels who resumed
anticoagulation, one had a major bleeding episode and two had recurrent VTE, for a composite result of 2.9%—a statistically significant difference (P<0.005). The group with normal D-dimer levels after initial
treatment had 24 episodes of recurrent VTE (6.2%).
The study suggested that the patients with abnormal D-dimer levels who stopped anticoagulation had a statistically significant higher rate
of recurrent VTE than those who continued anticoagulation. There was
also a statistically significant difference in the recurrent VTE rate in the
two groups who did not resume anticoagulation. Interestingly, while the
absolute difference between the normal D-dimer group and the abnormal D-dimer group who resumed anticoagulation was evident (6.2%
versus 2.9%), this did not reach statistical significance.
This study is promising; however, there are some caveats to take
into account when trying to apply these results to current clinical
practice. First, the trial was not blinded and only evaluated patients
with the first unprovoked episode of VTE. It is unknown if these results will apply to secondary VTE. Older people in this study had a
higher incidence of elevated D-dimer at enrollment. The authors utilized a qualitative assay for D-dimer to obtain uniform results across
the multiple testing centers. Applying these results to centers that use
quantitative measurements of D-dimer then becomes more difficult
due to the variability inherent in the interpretation of these quantitative results. Because this study excluded patients with either severe
liver disease or renal insufficiency (Cr >2.0), it remains unknown if
the results are applicable to these populations.
Because D-dimer levels were only measured once at the time of the
patients’ enrollment in the study, it is unknown if patients with normal
levels of D-dimer might progress to abnormal D-dimer levels and, therefore, to a potentially higher risk of VTE. This question could be answered with serial testing of D-dimer levels. The study was not powered
enough to detect relative risk of bleeding from anticoagulation alone.
Thus, these results were taken as a composite with the VTE events.
This study argues that anticoagulation in VTE patients with abnormal D-dimer levels measured after a month of stopping a standard
three-month course of anticoagulation should be continued. What is
not clear is whether we should continue treating people with normal Ddimer levels. Although not statistically significant, the absolute rate of
VTE of 6.2% in these patients was higher than the 2.9% rate in patients with high D-dimer levels who continued anticoagulation.
Early Administration of ACE
Inhibitors in MI Patients
Borghi C, Bacchelli S, Degli Esposti D, et al. Effects of early angiotensin-converting enzyme inhibition in patients with non-ST-elevation acute anterior myocardial infarction. Am Heart J. 2006 Sep;152(3):470-477.
Angiotensin-converting enzyme inhibitors (ACEIs) have demonstrated efficacy in improving long-term survival, particularly in patients
with ST-elevation MI (STEMI) with left ventricular dysfunction (LVD)
and/or congestive heart failure (CHF). There is less information available from clinical trial data, however, regarding the early use of ACEIs
with non-ST-elevation MI (NSTEMI) patients, who are believed to be
at an overall lower risk of in-hospital morbidity and mortality than
STEMI patients.
Researchers focused on the question of ACEI efficacy in NSTEMI
in a post hoc analysis of the patients enrolled in the Survival of Myocardial Infarction Long-term Evaluation (SMILE) study. The original
study enrolled 1,556 patients with anterior acute MI (AMI) who were
admitted to 154 coronary care units in Italy. Participants were patients
who presented with chest pain within 24 hours, who demonstrated electrocardiographic signs of anterior wall AMI, and who were not eligible
for thrombolytic therapy or reperfusion. These patients did receive beta
blockers, nitrates, analgesic agents, inotropic drugs, diuretic agents, and
anticoagulation agents as deemed appropriate.
Exclusion criteria included cardiogenic shock, systolic blood pressure below 100 mm Hg, serum creatinine above 2.5 mg per deciliter, a
history of CHF, prior treatment with ACEI, and contraindication to the
use of ACEI. Patients were randomized to either placebo or the shortacting ACEI zofenopril, with a starting dose of 7.5 mg every 12 hours.
CONTINUED ON PAGE
49
Perioperative Use of Beta Blockers to Reduce Ischemia
Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol nation of major cardiac events and death.
on mortality and cardiovascular morbidity after noncardiac
The results were striking. Of the 194 patients who survived to discharge,
surgery. Multicenter Study of Perioperative Ischemia Re- two-year follow-up data was available for 192. The two-year mortality rate in the
search Group. N Engl J Med. 1996 Dec 5;335(23):1713- treatment group was 55% lower (P=0.019), and the cardiac mortality rate was
1720.
65% lower (P=0.033). Ten patients in the control group died in the first six to
Prior to this landmark study, internists and cardiolo- eight months post-discharge, versus only one in the treatment group. Results
gists had few (if any) proven methods of reducing peri- in the secondary outcome were equally impressive, with a two-year decrease
operative cardiac morbidity and mortality. Although risk of 48% in the treatment group (P=0.008). Treated patients had a lower heart
stratification models such as
rate during treatment, and no patients required
the Goldman index had been
for hemodynamic instability due to the
The authors estimated that if this therapy
developed to permit clinicians to
drug.
intervention were administered
predict outcomes based on clinical
The authors estimated that if this intervention
criteria, the utility of interventions, inwere administered to all appropriate patients
to all appropriate patients each
cluding revascularization, was (and in some
each year, approximately 60,000 Americans
year, approximately 60,000
cases, remains) unknown. Work by Mangano
would then receive an extra two years of life. This
and others in the years preceding this study, howwas a dramatic conclusion at the time, but a subAmericans would then receive
ever, established that patients with coronary dissequent study by Poldermans and colleagues,
an extra two years of life.
ease, or cardiac risk factors, experienced iswho studied high-risk patients undergoing vaschemia during noncardiac surgery while under
cular surgeries, found equally dramatic short-term
general anesthesia and that such ischemia was a marker for increased long-term benefit from perioperative beta blockade.
mortality. The hypothesis was that perioperative beta blockers would reduce
Unfortunately, the study was open to a number of criticisms. Patients who
this ischemia and improve long-term surgical outcomes.
were already on beta blockers at the time of enrollment were taken off them imThis randomized, double-blind study included 200 Veterans Affairs patients mediately prior to the study; randomization did not distribute all variables equalin San Francisco, all of whom had known coronary artery disease or multiple risk ly; and the authors excluded from their analysis six patients who died in the imfactors. All underwent elective noncardiac surgery: general vascular, orthope- mediate postoperative setting. Further, recent studies of perioperative beta
dic, or intra-abdominal procedures. The intervention consisted of up to 10 mil- blockade on patients with clinical risk factors have not yielded similar benefits,
ligrams of intravenous atenolol or placebo administered in the hour prior to sur- although they also have not followed the same rigorous dosing regimen. Nevgery and immediately following, according to heart rate and blood pressure ertheless this study, which coincidentally was published just four months after
parameters. The study drug was continued from postoperative day one until the Wachter and Goldman “Sounding Board” piece in the New England Jourdischarge, up to a maximum of seven days. Patients were evaluated at six nal of Medicine ushered in the era of hospitalist medicine, opened the door for
months, at one year, and again two years after discharge. The primary outcome the systematic approach to medical perioperative risk attenuation that hospitalwas two-year all-cause mortality; the secondary outcome consisted of combi- ists today, ten years later, continue to champion.
CLASSIC
Literature
46
THE HOSPITALIST
> JANUARY 2007
Dr. Rigsby (left) and a Sherpa guide.
When this photo was taken, Dr.
Rigsby was battling pulmonary
edema on the Everest climb.
❚❘ By Larry Rigsby, MD
How I became my own patient while climbing Mount Everest
T
hirty years ago I was a medical resident at Duke University (Durham, N.C.). When I entered private practice
there was very little time for family, much less outside activities. Little did I know that I would become
a mountain climber with a desire to scale the world’s
highest mountain: Mount Everest at 29,035 feet.
As the years passed I learned that to stay healthy and
to meet all the demands that life seemed to dish out, I
needed some balance. So I learned to play as hard I
worked. I always loved to run and hike and eventually
became a competitive distance runner. I ran
marathons, including New York and Boston. I’ve also
competed in ultra-marathons ranging from 100- to
50,000- mile distances. I completed two of three
100-mile races, running one in 23 hours. My favorite trail ultra-marathons are in the mountains
of Colorado. My first 50-mile race was in the San Juan Mountains with elevations up to 12,000 feet.
My love of the mountains and endurance sports eventually led me to
rock climbing, ice climbing, and alpine mountaineering. I’ve climbed multiple alpine and ice routes in Colorado. I have also climbed Mount Rainier
(Washington state), and in the St. Elias, Chugach, and Alaskan ranges in
Alaska, including expeditions to Denali and Moose’s Tooth.
In 2003 I got my first taste of the Himalayas while climbing
Mount Ama Dablam—22,467 feet. Ama Dablam is a neighbor of
Everest’s and one of the most stunning mountains in the entire
Himalayan chain. I felt at home in the Himalayas and with the
Sherpa people of the region. I knew I would return and attempt Mount Everest. I eventually teamed up with a
Leadville, Colo.-based group of climbers who call themselves “Team No Limits.”
CONTINUED ON PAGE
48
Dr. Rigsby on the summit
of Ama Dablam in 2003.
THE HOSPITALIST
> JANUARY 2007
47
TO THE SUMMIT > CONTINUED FROM PAGE 47
In the spring of 2004 I joined an Everest Expedition
to the North—or Tibetan—side of Everest. I was only
permitted to climb to the North Col at 23,000 feet. I performed a full polysomnography (sleep study) at 21,000
feet, comparing the sleep of Sherpas with that of Western
climbers. This was valuable experience for my scheduled
summit attempt in 2006. (Interestingly, our oxygen saturations were all in the high 60s at that height, and we were
asymptomatic.)
Team No Limits worked hard in their preparation
for the 2006 expedition. We planned to climb from the
South—or Nepal—side of Everest, choosing the Hillary
or South Col route. We were extremely fortunate in that
we were able to contract with the legendary Apa Sherpa to
be our sirdar, or head Sherpa guide. Apa held the world’s
record for the most number of successful summit attempts
on Everest: 15.
Our four-member team departed for the mountain
in March 2006 with hopes
for a summit bid in late
April or early May. The
first stop was in Katmandu, Nepal, and then a
nine-day trek through the
Himalayas to the Everest
Base Camp. Shortly after
arrival at base camp one of
our team members became ill with altitude illness and subsequently had
to descend to a lower altitude to recover. Little did
we know that this would
be the second deadliest
season on Everest—second only to the 1996
climbing season.
On our climb the
team was struck by
tragedy. Early one morning several Team No Limits members were carrying
loads through the dreaded
Khumbu Ice Fall when a
large ice avalanche came
down, killing two of our
Sherpas and injuring several others. Initially we
were uncertain about continuing, but eventually we
decided to continue the
climb.
My expedition ended
shortly after the Sherpas’
deaths. One cold, windy
morning while climbing to
the top of the icefall, I noticed something was wrong.
My breathing became very
labored, and every step took
great effort. When I reached
the Western Cwm close to
Camp One I collapsed, unable to go farther. I knew I
was in grave trouble and
might not make it out alive.
I had pulmonary edema, a
condition I knew well from
my hospital experience, but
in a totally different setting.
Luckily, one of our
Sherpas came upon me
and assisted me to Camp
One. It was a long night,
but I survived with the assistance of my teammates
and Sherpas. I was already
on nifedipine for hypertension and as a prophylactic and acetazolamide
(Diamox) and was hypotensive. I took a sildenafil (Viagra; this is not at
48
THE HOSPITALIST
> JANUARY 2007
all funny if you don’t regularly use Viagra), which improved my pulmonary volume status. Sildenafil citrate inhibits cGMP specific phosphodiesterase type-5 in smooth
muscle, where it is responsible for degradation of cGMP;
it increases cGMP within vascular smooth muscle cells resulting in relaxation and vasodilation, leading to the vasodilation of my pulmonary vascular bed. This was the
only type of bed I was thinking about.
I was able to descend to Base Camp the next day and
felt better as I went to a lower altitude. But I knew my
climb was over. Another team member had a suspected
heart condition and was later airlifted off the mountain
by helicopter.
The rest of our team was eventually successful, however. The last man standing, Doug Tumminello, a lawyer from
Denver, successfully summitted the mountain on May 22.
Apa Sherpa also was successful, taking his world record from
15 to 16 summits.
Before returning home I trekked to the village of
Thame, Nepal, the home of the deceased Sherpas. I wanted to pay my respects to their families and friends.
Being a hospitalist suits my lifestyle very well. Now
I do a good job of working hard and playing hard. The
ability to play hard has allowed me to work even harder
and to keep my passion for medicine alive.
Now when I have a patient in pulmonary edema—
whatever the cause—I have a greater understanding of the
sensation and discomfort of dyspnea and the limitations
of the human body. Despite not summitting, I would not
have missed the ride for the world. I have no desire to
climb Everest again, but hope to continue climbing for
many years to come. TH
Dr. Rigsby, Everest climber and grandfather of eight, is a 55-year-old internal
medicine physician. He is a practicing hospitalist at Memorial Hospital in Chattanooga, Tenn., and a consultant for Eagle Hospitalists in Atlanta.
IN THE LITERATURE > CONTINUED FROM PAGE 46
The dose was progressively doubled until the final target
dose of 30 mg twice a day was reached. Upon completion of
a six-week double-blind period, the study medications were
stopped, but the patients continued taking their other medications for approximately 48 additional weeks, at which
time vital status was blindly obtained by questionnaire or
from registry offices. The primary endpoints were the occurrence of death or CHF during the treatment period.
In this post hoc analysis, only the 526 patients with anterior MI were studied. The baseline characteristics of the
placebo and zofenopril group were closely matched but were
predominantly male. The primary endpoint of this analysis
was the combined occurrence of death or severe CHF during the six weeks of treatment with zofenopril or placebo,
both given in addition to conventional treatment. Secondary
endpoints were the six-week occurrence of severe CHF, nonfatal MI or angina, and cumulative one-year mortality.
The findings of this analysis indicate a relative risk re-
duction (RRR) of 65% (95% CI 20%80%, 2P=0.003) of a
major cardiovascular event using zofenopril in the first 6
weeks of treatment. Cumulative incidence of combined
death and CHF was significantly (P=0.017) greater in the
placebo group than in the group of patients given zofenopril.
In addition, occurrence of severe CHF was lower in the
zofenopril group (RRR 84%, 95% CI 33%97%), as was
one-year mortality (RRR 43%, 95% CI 14%-57%,
2P=0.36). During the six weeks, there was a slightly lower
usage of beta blockers in the zofenopril group, as well as
lower usage of calcium channel blockers and diuretics in this
same group at one year. Systolic blood pressure (SBP) and
heart rate did not differ between the two groups.
The authors of this analysis concluded that early treatment for six weeks with zofenopril was effective in reducing
death and severe CHF in non-thrombolysed anterior wall
NSTEMI patients. The results were independent of SBP reduction, suggesting that zofenopril may have cardioprotec-
tive effects, preventing infarct expansion, left ventricular remodeling, and neurohormonal activation, which is involved
in coronary vasoconstriction and endothelial dysfunction.
Further, the relative risk reduction in composite endpoints
of mortality and severe CHF exceeded that observed in the
overall population in the SMILE trial (which included
STEMI), drawing attention to a particular advantage of the
early use of ACEI in NSTEMI patients.
Despite relevant findings, these results were derived
from a post hoc analysis of the SMILE study, only including about one third of the original population. It is also a
retrospective analysis, albeit recognizing the sparse availability of research in this area, thought to be related to the exclusion of such patients from most clinical trials. This analysis strongly highlights the beneficial effects of early
administration ACE inhibition and should prompt prospective evaluation of these agents as first-line therapy in anterior wall NSTEMI. TH
THE HOSPITALIST
> JANUARY 2007
49
> PRACTICE MANAGEMENT
Staffing Strategies
The benefits of varying the duration of the
work day and eliminating fixed duration shifts
❚❘ By John Nelson, MD, FACP
50
THE HOSPITALIST
> JANUARY 2007
ne of the most difficult challenges in
staffing a hospitalist practice is handling the unpredictable daily fluctuations in patient volume. It isn’t difficult to decide how many hospitalists will work each day
to handle the average number of daily visits
(aka encounters), but the actual number of
visits on any given day is almost always significantly different than the average. I think
many groups could more effectively handle
day-to-day variations in workload by elimi-
O
nating predetermined lengths of the shifts that the doctors
work. It isn’t a perfect strategy, but it is worth some consideration by nearly any practice. Let me explain.
First, think about how the workload for a typical day
might be represented. For many or most practices it often
looks something like the wavy line in Figure 1. (See Figure 1, p. 52.)
Of course, the line representing a day’s work will be
different every day, but I’ve tried to draw it in a way that
represents a typical day.
In Figure 2 (see p. 52), I’ve added horizontal bars to
represent a common way that groups might schedule four
daytime doctors who each work 7 a.m. to 7 p.m., and one
night doctor working 7 p.m. to 7 a.m. The four horizontal bars represent the four day doctors, and the one horizontal bar at the bottom right represents the one night
doctor. Ideally, the manpower (horizontal bars) should
match the workload (wavy line) every hour of the day.
This graph shows that—at least for this particular
day—there are many hours in the afternoon when there
is excess manpower. The doctors may be sitting around
waiting for their shift to end or waiting to see if it will
suddenly get busy again. We all know that happens unpredictably. And from about 7 p.m. to about 11:30 p.m.,
the single night doctor has more work than he/she can
reasonably handle.
In fact, there probably isn’t ever a day when the
work that needs to be done is just the right amount for
all four doctors from 7 a.m. to 7 p.m. with a sudden
drop at 7 p.m. that is just right for one doctor for the
next 12 hours. Because the doctors have scheduled
themselves to work 12-hour shifts, they know in advance
that their manpower will quite regularly fail to match
the workload for that
day.
Groups have devised a number of strategies to try to get manpower to more closely
match the unpredictable
workload for a given day.
These include having a
member of the group
available on standby
(often called “jeopardy”)
for that day; this physician comes in only if it is
unusually busy. Some
groups have a patient
volume cap to prevent
the practice from becoming too busy. I think
a cap is a poor strategy
that should be used only
as a last resort, and I will
discuss this in detail in a
future column. Other
groups have a swing shift
from late in the afternoon until around 11
p.m. or so to help with
evening admits and cross
cover. And an often
overlooked but potentially valuable strategy is
to eliminate clearly specified start and stop times
for the shifts that the
doctors work. For an
idea of what that might
look like, see Figure 3
(p. 52).
Notice that the
right-hand side of each
yellow bar in Figures 2
and 3 is indistinct. That
is meant to show that
the precise time that the
doctor leaves varies, depending on the day’s
workload. That way the
manpower can be adjusted from one day to
the next to more closely
match the workload
than if the doctors work
fixed shifts of a specified
duration. On some days,
all of the doctors may
stay 12 hours or more,
but on many days at
least some of the doctors
will end up leaving in
less than 12 hours. If all
day doctors work a 12hour shift, they have
provided 48 hours—
CONTINUED ON PAGE
THE HOSPITALIST
> JANUARY 2007
52
51
PRACTICE MANAGEMENT > CONTINUED FROM PAGE 51
Line trends down as
rounding work is done
Lots of
work to do
Shading above and to the right
of the line is excess
(unnecessary) manpower.
Admits from ER
typically pickup in
early afternoon and
gradually taper down
around midnight
Number
of
providers
in-house
Starting to wrap up
rounds, but ER not
yet busy w/ admits
Little work
to do
7A
3P
11A
Day shift
Open space below and to
the left of the line represents
insufficient manpower.
Starting to wrap up rounds, but
ER not yet busy w/ admits
7P
11P
3A
7A
7A
Night shift
11A
3P
Day shift
Figure 1
7P
11P
3A
7A
Night shift
Figure 2
These doctors generally leave when
their work is done, but may stay on
pager until 7 p.m. when the night
doc arrives.
Number of
providers
in-house
This doctor always stays
in-house until the night
doc arrives.
7A
3P
11A
Day shift
7P
11P
3A
7A
Night shift
eliminate precise times that the doctors start working in the morning each day,
though they might be required to be available by pager by a specified time in
the morning.
One common concern about such a system is how to handle issues that
arise with the patients cared for by a doctor who has left. I think it is best for
the doctor to stay available by pager and handle simple issues by phone. For
more complicated issues (e.g., a patient who needs attention at the bedside) the
doctor could either come back to the hospital or phone another member of the
practice (e.g., the doctor required to stay at least 12 hours that day) and see if
he or she can handle the emergency.
All of the specifics of a system that allows doctors to leave when their work
is done rather than according to shifts of a predetermined number of hours
would be too long for this column. But they aren’t complicated, and given the
variability that exists in the number of daily patient visits to any hospitalist
practice, the application of this kind of approach is well worth considering. TH
Figure 3
four doctors at 12 hours each—of physician manpower, but if there is some
flexibility about when the doctors leave, the same four day doctors could provide between about 34 and 52 hours of manpower, depending on the day’s
workload.
If your practice is contracted to keep a doctor in the hospital around the
clock, you will probably need the night doctor and at least one day doctor to
stay around—even if it is a slow day. But the other doctors might be able to
leave when their work is done. And it is also reasonable for some groups to
ZAPPING ZINGERS >
CONTINUED FROM PAGE
Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in
Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and
is not intended to reflect an official position of SHM.
DO YOU HAVE A PRACTICE DILEMMA OR QUESTION?
If so, we can help. E-mail Dr. Nelson in care of the The Hospitalist editorial office: [email protected].
Include your name, title, a full description of your dilemma or your question, and a daytime phone number.
We may include your query in an upcoming “Practice Management” column.
37
younger,’ and I take that as a compliment and laugh it off. I think most of the
time our patients are just curious. It may also be related to height, and several
of us speculate that shorter women may experience this more.”
Ian Jenkins, MD, a hospitalist at the University of California, San Diego,
and an associate professor of clinical medicine, shares this zinger: You don't
want to order this MRI for my back pain because it’s expensive, so
why don’t you just admit it?
His response: “That’s right. We have a certain amount of money to take
care of you and the rest of our patients and to do the best job possible. We
can’t waste any of it on unnecessary tests or therapies, so you’ve gotten exactly
what I would want if I had your back pain—a thorough history and
physical exam.”
Here are some zingers from Vijay Rajput, MD, senior hospitalist at Cooper University Hospital, Camden, N.J., associate professor of medicine and program director, Internal Medicine Residency Program, University of Medicine and Dentistry, Robert
Wood Johnson Medical School, Piscataway, N.J.º
1. Make sure you understand what the patient means. You may need to clarify a point until you
What’s going on [with my condition]? “Sometimes when
understand the intended meaning. For example, if the patient asks “Don’t you think that is a
I
say,
‘I don’t know,’ the patient comes back with, ‘How come you
lot of money?” you might ask, “What do you mean by ‘a lot of money?’ ”
don’t
know?’ I usually say, ‘Do you think that we need to know
Their concern may come from a lack of cash, a lot of debt, or a mistaken connection the
everything
in medicine?’ ” says Dr. Rajput. “They usually say, ‘No,
patient may have made between cost and the gravity of the situation. You can’t really know
not
necessarily,
but I thought for my condition you might know.’ ”
what the interpretation is unless you ask.
Dr. Rajput continues, “Sometimes I tell them, ‘Medicine has
2. Use the patient’s name frequently in the conversation—without sounding patronizing.
advanced too fast … many times we [need] more updated knowledge, and sometimes we are not updated … . I would rather update
3. Good answers don’t belittle patients or make them defensive.
the knowledge and do the right thing for you … than provide you
with care with a half-knowledge.’ Most of the people will like and
4. When under the pressure of a zinger, it’s easy to become flustered or vague, leave out imunderstand that answer.”
portant details, and wrongly assume that the patient knows what you’re talking about. Be deDr. Rajput tells another anecdote: “One time I was rounding
liberately clear.
with the team on the floor and we all—students, residents, a phar5. Slow down when answering a zinger, and keep your voice pitch and volume purposely low
macy student, and myself—were Asian, [with] three of [us] … born
and even. Don’t fidget or let your eyes wander.
here in the U.S. The patient asked, ‘How come there are too
many foreign doctors in this country?’
6. Good posture keeps you centered. Stand or sit up straight, and keep your head erect. Sit with
“That was a zinger,” recalls Dr. Rajput, “and my team thought
the patient if you can, and—above all—no matter what they’ve just asked or said, show you
I [would] pass [on it], but I didn’t. I gave the patient a straight ancare.
swer with a true explanation. It took a few minutes to explain it in
detail.
Source: Hills LS. How to answer the most common zinger questions. J Med Pract Manage.
“I asked him, ‘What is [your] perception?’ He did not have an
2005 Nov-Dec;21(3):153-155.
Guidelines for Responding
to Zinger Questions
CONTINUED ON PAGE
52
THE HOSPITALIST
> JANUARY 2007
83
5
Discussion
T
he answer is D: Wegener’s granulomatosis (WG) is a chronic
granulomatous inflammatory response of unknown etiology that
usually presents with the classic triad of systemic vasculitis, necrotizing granulomatous inflammation of the upper and lower respiratory
tracts, and glomerulonephritis. The generalized or classic form of
WG can progress rapidly to cause irreversible organ dysfunction and
death. Although the pathogenesis remains unknown, it is felt that
WG may result from an exaggerated cell-mediated response to an
unknown antigen.1
The average age of onset for WG is 45.2 years, with 63.5% of
patients male and 91% Caucasian.2 A WG diagnosis can be very difficult, and elements of the classic triad may not all be present initially. Pulmonary infiltrates or nodules are seen via chest X-ray or CT
scan in just less than half of patients as an early manifestation of WG.
Occasionally WG presents with skin lesions (13%) or oral ulcers
(6%), however, 40% of patients eventually develop skin involvement
consisting of painful subcutaneous nodules, papules, vesicles or bullae, petechiae, palpable purpura, and pyoderma gangrenosum-like
lesions.3 Histologic evaluation of these skin lesions reveals non-specific perivascular lymphocytic inflammation, leukocytoclastic vasculitis-like changes, palisading granulomas, and granulomatous vasculitis; however, it is rare to see granulomatous vasculitis or palisading
necrotizing granulomas in skin specimens.4,5
WG can also affect the eyes, heart, respiratory system, nervous
system, kidneys, and joints.6 The upper respiratory tract is involved
in the majority of patients, and symptoms reflecting otitis, epistaxis,
rhinorrhea, or sinusitis are common and may be the first manifestation of disease. When mucosal necrotizing granulomas occur, they
can result in the typical saddle nose deformity seen in patients with
WG. Lower respiratory tract involvement is also common and can
present with cough, dyspnea, chest pain, and hemoptysis.1
Patients with WG usually have a positive c-ANCA, however this
is not specific for WG and may also indicate Churg-Strauss Syndrome and microscopic polyarteritis. The median survival of patients
with untreated WG is five months, and corticosteroids used alone
do not change this median survival. When corticosteroids are combined with cytotoxic agents, such as cyclophosphamide, the prognosis significantly improves in greater than 90% of patients, with a 75%
remission rate, and an 87% survival of patients followed from six
months to 24 years.3 TH
>
CONTINUED FROM PAGE
REFERENCES
1. Hannon CW, Swerlick RA. Vasculitis. In: Bolognia JL, Jorizzo JL, Rapini RP, et al, eds. Dermatology. Vol 1. New York: Elsevier Limited; 2003: 393-395.
2. Cotch MF, Hoffman GS, Yerg DE, et al. The epidemiology of Wegener’s granulomatosis. Estimates of the five-year period prevalence, annual mortality, and geographic disease distribution
from population-based data sources. Arthritis Rheum. 1996 Jan;39(1):87-92.
3. Hoffman GS, Kerr GS, Leavitt RY, et al. Wegener granulomatosis: an analysis of 158 patients. [see comments]. Ann Int Med. 1992;116:488-498.
4. Hu CH, O’Loughlin S, Winkelmann RK. Cutaneous manifestations of Wegener granulomatosis. Arch Dermatol. 1997;113(2):175-182.
5. Lie JT. Wegener’s granulomatosis: histological documentation of common and uncommon
manifestations in 216 patients. Vasa. 1997;26:261-270.
6. Yi ES, Colby TV. Wegener’s granulomatosis. Semin Diagn Pathol. 2001 Feb;18(1):34-46.
WHAT’S YOUR
DIAGNOSIS?
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THE HOSPITALIST
> JANUARY 2007
81
> PROGRESS NOTES
Hospitology
The hospitable hospital
❚❘ By James S. Newman, MD, FACP, HIP*
A
mong the newest fields in medicine, the specialty “hospitology” applies the precepts of the hospitality industry to the
hospital environment.
INTRODUCTION
The hospitology industry celebrated its fifth birthday this year. The
term was coined by health consumer advocate Katy Ericson and
was actualized by the daughter of a hotel industry mogul, Marseilles
Hyatt. Like their colleagues in other new specialties, including
forensic proctology and cosmetic gynecology, “hospitologists” have
organized and worked hard to define their specialty and are working toward board certification.
SCOPE OF PRACTICE
Though it is often difficult to obtain
blood without a phlebotomy and a
needle, the hospitologist should be
at the bedside to hold the visitor’s
hand, and (if need be) should offer
their own blood—if the visitor cannot
bear the thought of “getting stuck.”
Hospitologists have expertise in
making the “visitors” feel welcome
in the hospital environment.
(Hospitologists prefer to refer to
patients as “visitors,” though they
also use the term “customer.”) As
the visitor arrives from admissions,
the hospitologist is waiting at bedside. The hospitologist assures the
visitor that all his needs will be
met in his personalized care suite.
Subsequent to the greeting,
the hospitologist assists in the selection of an appropriate gown,
termed “hospital attire.” There are several modish alternatives from
designers such as Yves Saint Levaquin, Pierre Cardiac, and Club
Medicare.
Obtaining a history and completing a physical remain a necessary part of the hospitalization experience, and hospitologists
know how to establish a peaceful rapport. Previous review of material excludes the need to spend time on such distractions as past
medical history or medication list, though many patients wish to
discuss these at excruciating length. If this is the case, the hospitologist is ready to sit quietly while the visitor reviews any or all details
of medical encounters—tangential or otherwise.
Prior to a physical exam, the patient may opt for a massage or
a nap, either of which can be arranged for an extra charge.
Physical exams by hospitologists are soothing and precise,
though not strictly required. Studies show that the physical exam is
of low sensitivity and specificity. Nonetheless, the use of a stethoscope is encouraged to create the sense of clinical competence that
visitors prefer in care providers, though having the gadget draped
around one’s neck is, in most cases, sufficient.
Admission orders are a true art form. Administer adequate narcotics, benzodiazepines, and an antidepressant to visitors—whether
they truly need them or not. Gently encourage smokers to quit;
however, if they choose not to, then a selection of fine brands
should be available for purchase and delivery to the care suite. Most
modern hospitology programs offer online ordering through the
in-care suite entertainment system, which features a selection of
cigarettes, alcohol, and other needed substances, for a small additional fee. The concierge may be of help as well.
When it comes to diagnostic testing, there is no provider more
adept at meeting a visitor’s needs than a hospitologist. Whether the
visitor desires a barium enema or a PET scan, the test will be
arranged immediately. Lab work may also be ordered. Though it is
often difficult to obtain blood without a phlebotomy and a needle,
the hospitologist will at bedside to hold the visitor’s hand, and (if
need be) can offer her own blood if the visitor cannot bear the
thought of “getting stuck.” There is an extra fee for this service,
however.
Hospitologists command the full range of therapeutic maneu-
82
THE HOSPITALIST
> JANUARY 2007
vers including heavy water hydrotherapy, splenic massage, and isotope enemas.
At time of discharge the hospitologist will have the visitor
ready to go—both medically and spiritually. If he has no ride or it’s
just too rainy, discharge on an alternate night is always an option.
Visitors are always welcomed back, even if it’s within 30 days and
with the same diagnosis.
HOSPITOLOGIST METRICS
Length of stay (LOS) is an important metric for any hospitologist.
LOS less than eight days may be a measure of poor performance,
though we frequently see a four-day, three-night weekend admission
for the busy executive.
The 30-day readmission rate is also worth following, as a
happy visitor will want to return to the healing environment.
Cost per admission is of no importance; hospitologists live to
serve, and finances are just a distraction from our duties. Money is
the root of all evil, and hospitologists are well rooted.
Hospitologists rely heavily on EBM—experience-based medicine. Statistics can lie, but a happy smiling patient remains the
proof in the hospitologist’s pudding. (Multiple flavors are available;
see the menu.)
ORGANIZED MEDICINE AND CERTIFICATION
Like all good practitioners of new specialties, the hospitologists of
America are well represented. The original organization was called
Hospitology Organization of Haversend, Ohio (HOHO), which
merged with the Hospitologist Organization of Rybeck, N.Y.,
(HORNY), to form the American Clinical Hospitology Organization (ACHOO), Gesundheit.
The current CEO of ACHOO Gesundheit is Moe Larryundcurly. He has represented the organization for several years and has
been acknowledged by his peers to be “outstanding,” though at the
time, they were all “in” and “sitting.”
The move for Bored Certification is in the air for ACHOO
Gesundheit. Every hospitology program wants to have certified hospitologists. The ABIM (American Bored of Internal Medicine) and
the ACP (Association of Credentialed Persons) have generally been
supportive of Bored Certification, despite distraction from rival
groups, such as the Socialist Generic Inpatient Medicos and other
nefarious organizations.
Criteria for Bored Certification includes the following: Being
bored at committee meetings, providing room and board for me
when I visit, and the ability to tolerate being bored stiff, to death,
and to tears.
THE FUTURE
The future is bright for hospitologists. Changes in Medicare billing,
support from the hotel industry, and association with other “ologists,” such as cosmetologists and herpetologists, will only make the
group stronger. Major threats to the specialty include tort law, outcomes analysis, and my brother Seymour, the crooked shyster
lawyer.
Next time you go to the hospital to be “healed,” ask for a hospitologist! TH
*Hospitologist in practice
Conflict of interest statement: Dr. Newman does not own 25% of common shares of Hospitologists Incorporated (HI), although his wife does.
Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal
Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College
of Medicine, Rochester, Minn.
answer. I explained to him that 25% of [the] doctors [in
the U.S.] are not born in this country, and we have a constant need for more doctors. We have proper mechanisms
[in place] so that these doctors are trained as well as in
American schools and residencies before they start their
practice. I also explained the relationships with Educational Commission for Foreign Medical Graduates
(ECFMG), National Board of Medical Examiners
(NBME), and Council for Graduate Medical Education
(ACGME) and said that three out of four of us are U.S.born and not ‘foreign’ doctors.”
David M. Grace, MD, of The Schumacher Group
is a hospitalist practice director in Lafayette, La.; he remembers this zinger: If it’s OK with you, I’d like to
stay today and go home tomorrow.
“At least once a week, I have a patient who just doesn’t feel up to going home at the appropriate time of discharge. My response always starts with ‘Why?’ All patients
have the right to a safe and stable discharge from the hospital, and it’s important to ensure that no pertinent issues
have been overlooked. Is their home support system not ready yet? Is payday tomorrow, and they can’t afford their medicines today? Are they just scared?
“Once I’m satisfied that no occult
dangers exist, I sit and discuss the situation with the patient. I first remind them
of our discussion … at admission; it’s the
same discussion I have with every patient,” says Dr. Grace. “During the admission process, I outline what objectives
need to be reached prior to discharge. I
emphasize that the role of hospitalization
is not to cure the patient but to ‘rectify
the problems that require inpatient care’
and allow the convalescence to take place
at home.
“Occasionally I have patients [with
whom] my first-line strategy doesn’t
work, and I move on to plan B. Plan B is
where I quote statistics such as, ‘100,000
patients per year die in hospitals due to
errors, and on average, each inpatient will
have one medication error per day.’ Continuing to stay in the hospital beyond
today will shift the risk/benefit ratio to a
position where the patient would have
additional risk but no additional medical
benefit.
“Plan C is rarely used, but it’s in my
arsenal,” he says. “I remind the patient
that I’m responsible for doing what is
medically appropriate, and I reiterate that
I understand their concerns, but I cannot
commit healthcare fraud by documenting that the patient is not stable for discharge when they are stable. I then shift
the decision back to the patient by closing with, ‘We don’t force patients to leave
or drag them out of the hospital; however, you need to check with your insurance
carrier about whether they will cover the
cost of a non-necessary additional hospital day.’ I inform them that the hospital
will likely charge the additional day to
the patient, and I don’t want to see them
get an unexpected bill.”
Another of the zingers Dr. Grace has
dealt with: I’m supposed to have test
X done as an outpatient, but now
that I’m here in the hospital, can we
just do it now?
“On days where Lady Luck is shining on me, it’s a test we need to do as part
of [the patient’s] acute work-up, and
everything works out well. More often
than not, it’s a test or procedure unrelated to the admitting diagnoses and one
[that] is far more expensive to do as an
inpatient, compared with an outpatient
study.
“When possible, I’ll explain to the
patient that the test they want may not
be accurate in the setting of an acute illness, such as the
test for lipid levels,” he says. “If the test doesn’t fit into
that category, I’ll explain—depending on the request,
such as one for an MRI or CT—that they may make it
halfway through the test, and the test will need to be
aborted because of an acutely sick patient who requires
immediate intervention using that piece of equipment,
which for the patient would mean that they may need to
go through the procedure a second time, or possibly even
a third.
“Failing that approach,” he continues, “I often make
the insurance company the ‘bad one’ and inform them
that their carrier may not pay for the test as an inpatient
as it’s not related to their medical illness, and they should
check to ensure that the bill won’t be passed on to them.
Often the patient, who knows how much of a headache
it can be to deal with their insurance company, will drop
the request.” TH
ZAPPING ZINGERS >
REFERENCES
CONTINUED FROM PAGE
52
1. Hills LS. How to answer the most common zinger questions. J Med Pract
Manage. 2005 Nov-Dec;21(3):153-155.
2. Lo B. Ethical and policy implications of hospitalist systems. Am J Med.
2001;111:48-52.
It’s Easy to Contact
The Hospitalist Editors!
Lisa Dionne, editor E-mail:
[email protected] Phone:
(201) 748-5880
Jamie Newman, MD, physician
editor E-mail: [email protected]
Andrea Sattinger writes frequently for The Hospitalist.
THE HOSPITALIST
> JANUARY 2007
83