Gina Gotsill

Kenneth Duckworth, MD, medical director at Vinfen Corporation in Boston, recalls the frustration he felt when inpatient hospital staff would release his psychiatric patients without contacting him. The lack of communication often led to gaps in his patients’ records and left him scrambling to learn more about the circumstances of the hospitalization.

Those experiences are among the reasons Dr. Duckworth, a triple-board-certified psychiatrist and medical director of the National Alliance on Mental Illness (NAMI), was pleased to hear The Joint Commission had released its Hospital-Based Inpatient Psychiatric Services, or HBIPS, measure set. And he’s not alone. HBIPS provides standardized measures for psychiatric services where previously none existed, and it gives hospitals the ability to use their data as a basis for national comparison.

Ann Watt, associate director, division of quality measurement and research at the Joint Commission, says although it’s still early, the measures seem to be working. “While we don’t have any actual data, we have received positive feedback,” she says. “It seems like the field has accepted them well.”

Standard of Care Guidelines

Comprised of seven main measures that the commission released in October 2008, HBIPS is the result of a determined effort by the nation’s psychiatry leaders, says Noel Mazade, PhD, executive director of the National Association of State Mental Health Program Directors’ Research Institute Inc. HBIPS is available to hospitals accredited under the Comprehensive Accreditation Manual for Hospitals (CAMH), says Celeste Milton, associate project director at the commission’s Department of Quality Measurement. Free-standing psychiatric hospitals and acute-care hospitals with psychiatric units can use the HBIPS measure set to help meet performance requirements under the commission’s ORYX initiative (www. jointcommission.org/AccreditationPrograms/Hospitals/ORYX/).

The Joint Commission’s final HBIPS measure set, which went into effect with Oct. 1, 2008, discharges, followed more than three years’ of field review, public comment, and pilot testing by 196 hospitals across the country. HBIPS’ seven measures address:

1. Admission screening;
2. Hours of physical restraint;
3. Hours of seclusion;
4. Patients discharged on multiple antipsychotic medications;
5. Patients discharged on multiple antipsychotic medications with appropriate justification;
6. Post-discharge plan creation; and
7. Post-discharge plans transmitted to the next level of care provider.

“These are all areas that are of interest to NAMI,” Dr. Duckworth says. “We still have a long way to go, but it’s definitely a step in the right direction.”

The measure set’s effect on psychiatric hospitalists will depend on physicians’ responsibilities at the facilities where they work, Milton says. For example, a psychiatric hospitalist may be asked to screen a patient at admission for violence risk, substance abuse, psychological trauma history, and strengths, such as personal motivation and family involvement (HBIPS Measure 1). Another qualified psychiatric practitioner, such as a psychiatrist, registered nurse, physician’s assistant, or social worker, could perform the screening, she says.

The measures are intended to help unify the screening process used by psychiatric hospitalists; however, traditional hospitalists could be called on to perform a face-to-face evaluation of a patient placed in physical restraint or held in seclusion (Measures 2 and 3). As a result of the evaluation, hospitalists could be asked to write orders to discontinue or renew physical restraint or seclusion, Milton says. The feedback the Joint Commission has received shows psychiatric hospitalists are using the measures. They are most likely to be in charge of managing a patient’s medications and could play a role in documenting appropriate justification for placing a patient on more than one antipsychotic medication at discharge (Measures 4 and 5). Depending on the scope of practice, traditional hospitalists who discharge patients might be responsible for determining a final discharge diagnosis, discharge medications, and next-level-of-care recommendations (Measures 6 and 7). The provider at the next level of care could be an inpatient or outpatient clinician or entity, Milton says.

How It Works

The HBIPS data collection process is similar to other ORYX processes; however, this is the first time the Joint Commission has created a measure set for psychiatric services, says Dr. Mazade, who worked directly with the commission to develop HBIPS. Hospitals using HBIPS will submit data from patients’ medical records to their ORYX vendor. The vendor will submit performance measures to the hospital and the commission, which will provide hospitals with feedback on measure performance, Dr. Mazade says. Initially, the commission will supply acute-care and psychiatric hospitals the option of using HBIPS to meet current ORYX performance measurement requirements, although Dr. Mazade says he expects the commission will eventually mandate use of the measures.

The commission says data collection, analysis, and performance reporting is running behind schedule. Once the commission report is received, hospitals should share the message with their medical staff, Milton says. “This feedback will be useful to all staff involved in patient care to help them improve their practice,” she explains. “The purpose of an initial screening, including a trauma history, is to help the practitioner formulate an individual treatment plan based on information obtained during the initial screening.”

Tim Lineberry, MD, medical director at the Mayo Clinic Psychiatric Hospital in Rochester, Minn., says each HBIPS measure is composed of sub-elements. For example, the assessment measure includes admission screening for violence risk, substance abuse, trauma history, and patient strengths, such as motivation and family involvement. These elements create a more complete picture of the patient and might improve the initial assessment. By improving initial assessment, experts in the field hope hospital staff will be able to better identify problems, Dr. Lineberry says.

“We are all working for improvement in care,” says Dr. Lineberry, noting the Mayo Clinic was one of the pilot sites. “HBIPS is part of that effort.”

Time Is of the Essence

Many of the standards represent areas in which there is consensus among psychiatrists about the need for change, says Anand Pandya, MD, a psychiatric hospitalist and director of inpatient psychiatry at Cedars-Sinai Medical Center in Los Angeles. Many psychiatrists recognize there is a need to improve communication between inpatient psychiatric services and follow-up outpatient providers, Dr. Pandya says. However, a clear consensus has not been reached regarding the standards of tracking patients who take multiple antipsychotic medications, Dr. Pandya says.

“With the low average length of stay in inpatient psychiatric units, it is common for patients to continue a cross-taper between medications after discharge,” Dr. Pandya says. “For most antipsychotic medications, there is insufficient data to determine how fast or slow to cross-taper. I worry that these standards may send the unintentional message that these cross-tapers should be completed quickly during the course of a brief inpatient stay.”

Data suggest individuals using lithium should be tapered off the drug as slowly as possible—probably over months rather than weeks, Dr. Pandya says. “I am concerned that tracking data regarding patients on multiple antipsychotic medications may create incentives to change practice in a sub-optimal direction for some cases,” he says.

Dr. Duckworth also acknowledges patients’ length of stay is getting shorter. Psychiatric hospitalists are under a great deal of pressure to “get people patched up in too short a period of time,” he says. “They really do need more time. There is a temptation to use more than one antipsychotic medication, but people really should not be given two antipsychotic medications unless someone has performed a thoughtful assessment.”

On Board with HBIPS

While HBIPS covers areas of care important to many, the details of implementing the measure set might be challenging, Dr. Lineberry says. The requirements increase the documentation burden for physicians, nurses, and allied health professionals, such as social workers and therapists. Hospitals using electronic medical records might have to modify their records to meet the requirements. And with the new measure comes new, significant personnel costs to audit and collect the data, he says.

“For psychiatric hospitalists who are using HBIPS, it will be helpful to look at the measures from a multidisciplinary standpoint,” Dr. Lineberry says. “Approach HBIPS as a team. Look at the process and see how it works, then adapt it to fit in with your current workflow.”

As of July, more than 274 psychiatric hospitals and psychiatric units had implemented the HBIPS measures. “We don’t usually have numbers until at least six months after,” Milton says, noting the commission is eager to receive quantitative data and report back to the participating hospitals.

Milton anticipates the Joint Commission will submit the HBIPS measure set to the National Quality Forum (NQF) for consideration and endorsement. Although she anticipates the measures will receive NQF endorsement sometime this year, an exact timeline has not been established, she says. The Joint Commission will work closely with the NQF to ensure the HBIPS measure set receives endorsement, and will make necessary modifications that may be required, Milton says.

Once HBIPS receives NQF endorsement, HBIPS data will be publicly reported following the first two quarters of data collection, Milton says. Data on each hospital will be available at www.qualitycheck.org. TH

Gina Gotsill is a freelance medical writer in California. Freelance writer Chris Haliskoe contributed to this report.

Image Source: TIM TEEBKEN/PHOTODISC

Kenneth Duckworth, MD, medical director at Vinfen Corporation in Boston, recalls the frustration he felt when inpatient hospital staff would release his psychiatric patients without contacting him. The lack of communication often led to gaps in his patients’ records and left him scrambling to learn more about the circumstances of the hospitalization.

Those experiences are among the reasons Dr. Duckworth, a triple-board-certified psychiatrist and medical director of the National Alliance on Mental Illness (NAMI), was pleased to hear The Joint Commission had released its Hospital-Based Inpatient Psychiatric Services, or HBIPS, measure set. And he’s not alone. HBIPS provides standardized measures for psychiatric services where previously none existed, and it gives hospitals the ability to use their data as a basis for national comparison.

Ann Watt, associate director, division of quality measurement and research at the Joint Commission, says although it’s still early, the measures seem to be working. “While we don’t have any actual data, we have received positive feedback,” she says. “It seems like the field has accepted them well.”

Standard of Care Guidelines

Comprised of seven main measures that the commission released in October 2008, HBIPS is the result of a determined effort by the nation’s psychiatry leaders, says Noel Mazade, PhD, executive director of the National Association of State Mental Health Program Directors’ Research Institute Inc. HBIPS is available to hospitals accredited under the Comprehensive Accreditation Manual for Hospitals (CAMH), says Celeste Milton, associate project director at the commission’s Department of Quality Measurement. Free-standing psychiatric hospitals and acute-care hospitals with psychiatric units can use the HBIPS measure set to help meet performance requirements under the commission’s ORYX initiative (www. jointcommission.org/AccreditationPrograms/Hospitals/ORYX/).

The Joint Commission’s final HBIPS measure set, which went into effect with Oct. 1, 2008, discharges, followed more than three years’ of field review, public comment, and pilot testing by 196 hospitals across the country. HBIPS’ seven measures address:

1. Admission screening;
2. Hours of physical restraint;
3. Hours of seclusion;
4. Patients discharged on multiple antipsychotic medications;
5. Patients discharged on multiple antipsychotic medications with appropriate justification;
6. Post-discharge plan creation; and
7. Post-discharge plans transmitted to the next level of care provider.

“These are all areas that are of interest to NAMI,” Dr. Duckworth says. “We still have a long way to go, but it’s definitely a step in the right direction.”

The measure set’s effect on psychiatric hospitalists will depend on physicians’ responsibilities at the facilities where they work, Milton says. For example, a psychiatric hospitalist may be asked to screen a patient at admission for violence risk, substance abuse, psychological trauma history, and strengths, such as personal motivation and family involvement (HBIPS Measure 1). Another qualified psychiatric practitioner, such as a psychiatrist, registered nurse, physician’s assistant, or social worker, could perform the screening, she says.

The measures are intended to help unify the screening process used by psychiatric hospitalists; however, traditional hospitalists could be called on to perform a face-to-face evaluation of a patient placed in physical restraint or held in seclusion (Measures 2 and 3). As a result of the evaluation, hospitalists could be asked to write orders to discontinue or renew physical restraint or seclusion, Milton says. The feedback the Joint Commission has received shows psychiatric hospitalists are using the measures. They are most likely to be in charge of managing a patient’s medications and could play a role in documenting appropriate justification for placing a patient on more than one antipsychotic medication at discharge (Measures 4 and 5). Depending on the scope of practice, traditional hospitalists who discharge patients might be responsible for determining a final discharge diagnosis, discharge medications, and next-level-of-care recommendations (Measures 6 and 7). The provider at the next level of care could be an inpatient or outpatient clinician or entity, Milton says.

How It Works

The HBIPS data collection process is similar to other ORYX processes; however, this is the first time the Joint Commission has created a measure set for psychiatric services, says Dr. Mazade, who worked directly with the commission to develop HBIPS. Hospitals using HBIPS will submit data from patients’ medical records to their ORYX vendor. The vendor will submit performance measures to the hospital and the commission, which will provide hospitals with feedback on measure performance, Dr. Mazade says. Initially, the commission will supply acute-care and psychiatric hospitals the option of using HBIPS to meet current ORYX performance measurement requirements, although Dr. Mazade says he expects the commission will eventually mandate use of the measures.

The commission says data collection, analysis, and performance reporting is running behind schedule. Once the commission report is received, hospitals should share the message with their medical staff, Milton says. “This feedback will be useful to all staff involved in patient care to help them improve their practice,” she explains. “The purpose of an initial screening, including a trauma history, is to help the practitioner formulate an individual treatment plan based on information obtained during the initial screening.”

Tim Lineberry, MD, medical director at the Mayo Clinic Psychiatric Hospital in Rochester, Minn., says each HBIPS measure is composed of sub-elements. For example, the assessment measure includes admission screening for violence risk, substance abuse, trauma history, and patient strengths, such as motivation and family involvement. These elements create a more complete picture of the patient and might improve the initial assessment. By improving initial assessment, experts in the field hope hospital staff will be able to better identify problems, Dr. Lineberry says.

“We are all working for improvement in care,” says Dr. Lineberry, noting the Mayo Clinic was one of the pilot sites. “HBIPS is part of that effort.”

Time Is of the Essence

Many of the standards represent areas in which there is consensus among psychiatrists about the need for change, says Anand Pandya, MD, a psychiatric hospitalist and director of inpatient psychiatry at Cedars-Sinai Medical Center in Los Angeles. Many psychiatrists recognize there is a need to improve communication between inpatient psychiatric services and follow-up outpatient providers, Dr. Pandya says. However, a clear consensus has not been reached regarding the standards of tracking patients who take multiple antipsychotic medications, Dr. Pandya says.

“With the low average length of stay in inpatient psychiatric units, it is common for patients to continue a cross-taper between medications after discharge,” Dr. Pandya says. “For most antipsychotic medications, there is insufficient data to determine how fast or slow to cross-taper. I worry that these standards may send the unintentional message that these cross-tapers should be completed quickly during the course of a brief inpatient stay.”

Data suggest individuals using lithium should be tapered off the drug as slowly as possible—probably over months rather than weeks, Dr. Pandya says. “I am concerned that tracking data regarding patients on multiple antipsychotic medications may create incentives to change practice in a sub-optimal direction for some cases,” he says.

Dr. Duckworth also acknowledges patients’ length of stay is getting shorter. Psychiatric hospitalists are under a great deal of pressure to “get people patched up in too short a period of time,” he says. “They really do need more time. There is a temptation to use more than one antipsychotic medication, but people really should not be given two antipsychotic medications unless someone has performed a thoughtful assessment.”

On Board with HBIPS

While HBIPS covers areas of care important to many, the details of implementing the measure set might be challenging, Dr. Lineberry says. The requirements increase the documentation burden for physicians, nurses, and allied health professionals, such as social workers and therapists. Hospitals using electronic medical records might have to modify their records to meet the requirements. And with the new measure comes new, significant personnel costs to audit and collect the data, he says.

“For psychiatric hospitalists who are using HBIPS, it will be helpful to look at the measures from a multidisciplinary standpoint,” Dr. Lineberry says. “Approach HBIPS as a team. Look at the process and see how it works, then adapt it to fit in with your current workflow.”

As of July, more than 274 psychiatric hospitals and psychiatric units had implemented the HBIPS measures. “We don’t usually have numbers until at least six months after,” Milton says, noting the commission is eager to receive quantitative data and report back to the participating hospitals.

Milton anticipates the Joint Commission will submit the HBIPS measure set to the National Quality Forum (NQF) for consideration and endorsement. Although she anticipates the measures will receive NQF endorsement sometime this year, an exact timeline has not been established, she says. The Joint Commission will work closely with the NQF to ensure the HBIPS measure set receives endorsement, and will make necessary modifications that may be required, Milton says.

Once HBIPS receives NQF endorsement, HBIPS data will be publicly reported following the first two quarters of data collection, Milton says. Data on each hospital will be available at www.qualitycheck.org. TH

Gina Gotsill is a freelance medical writer in California. Freelance writer Chris Haliskoe contributed to this report.

Image Source: TIM TEEBKEN/PHOTODISC

Kenneth Duckworth, MD, medical director at Vinfen Corporation in Boston, recalls the frustration he felt when inpatient hospital staff would release his psychiatric patients without contacting him. The lack of communication often led to gaps in his patients’ records and left him scrambling to learn more about the circumstances of the hospitalization.

Those experiences are among the reasons Dr. Duckworth, a triple-board-certified psychiatrist and medical director of the National Alliance on Mental Illness (NAMI), was pleased to hear The Joint Commission had released its Hospital-Based Inpatient Psychiatric Services, or HBIPS, measure set. And he’s not alone. HBIPS provides standardized measures for psychiatric services where previously none existed, and it gives hospitals the ability to use their data as a basis for national comparison.

Ann Watt, associate director, division of quality measurement and research at the Joint Commission, says although it’s still early, the measures seem to be working. “While we don’t have any actual data, we have received positive feedback,” she says. “It seems like the field has accepted them well.”

Standard of Care Guidelines

Comprised of seven main measures that the commission released in October 2008, HBIPS is the result of a determined effort by the nation’s psychiatry leaders, says Noel Mazade, PhD, executive director of the National Association of State Mental Health Program Directors’ Research Institute Inc. HBIPS is available to hospitals accredited under the Comprehensive Accreditation Manual for Hospitals (CAMH), says Celeste Milton, associate project director at the commission’s Department of Quality Measurement. Free-standing psychiatric hospitals and acute-care hospitals with psychiatric units can use the HBIPS measure set to help meet performance requirements under the commission’s ORYX initiative (www. jointcommission.org/AccreditationPrograms/Hospitals/ORYX/).

The Joint Commission’s final HBIPS measure set, which went into effect with Oct. 1, 2008, discharges, followed more than three years’ of field review, public comment, and pilot testing by 196 hospitals across the country. HBIPS’ seven measures address:

1. Admission screening;
2. Hours of physical restraint;
3. Hours of seclusion;
4. Patients discharged on multiple antipsychotic medications;
5. Patients discharged on multiple antipsychotic medications with appropriate justification;
6. Post-discharge plan creation; and
7. Post-discharge plans transmitted to the next level of care provider.

“These are all areas that are of interest to NAMI,” Dr. Duckworth says. “We still have a long way to go, but it’s definitely a step in the right direction.”

The measure set’s effect on psychiatric hospitalists will depend on physicians’ responsibilities at the facilities where they work, Milton says. For example, a psychiatric hospitalist may be asked to screen a patient at admission for violence risk, substance abuse, psychological trauma history, and strengths, such as personal motivation and family involvement (HBIPS Measure 1). Another qualified psychiatric practitioner, such as a psychiatrist, registered nurse, physician’s assistant, or social worker, could perform the screening, she says.

The measures are intended to help unify the screening process used by psychiatric hospitalists; however, traditional hospitalists could be called on to perform a face-to-face evaluation of a patient placed in physical restraint or held in seclusion (Measures 2 and 3). As a result of the evaluation, hospitalists could be asked to write orders to discontinue or renew physical restraint or seclusion, Milton says. The feedback the Joint Commission has received shows psychiatric hospitalists are using the measures. They are most likely to be in charge of managing a patient’s medications and could play a role in documenting appropriate justification for placing a patient on more than one antipsychotic medication at discharge (Measures 4 and 5). Depending on the scope of practice, traditional hospitalists who discharge patients might be responsible for determining a final discharge diagnosis, discharge medications, and next-level-of-care recommendations (Measures 6 and 7). The provider at the next level of care could be an inpatient or outpatient clinician or entity, Milton says.

How It Works

The HBIPS data collection process is similar to other ORYX processes; however, this is the first time the Joint Commission has created a measure set for psychiatric services, says Dr. Mazade, who worked directly with the commission to develop HBIPS. Hospitals using HBIPS will submit data from patients’ medical records to their ORYX vendor. The vendor will submit performance measures to the hospital and the commission, which will provide hospitals with feedback on measure performance, Dr. Mazade says. Initially, the commission will supply acute-care and psychiatric hospitals the option of using HBIPS to meet current ORYX performance measurement requirements, although Dr. Mazade says he expects the commission will eventually mandate use of the measures.

The commission says data collection, analysis, and performance reporting is running behind schedule. Once the commission report is received, hospitals should share the message with their medical staff, Milton says. “This feedback will be useful to all staff involved in patient care to help them improve their practice,” she explains. “The purpose of an initial screening, including a trauma history, is to help the practitioner formulate an individual treatment plan based on information obtained during the initial screening.”

Tim Lineberry, MD, medical director at the Mayo Clinic Psychiatric Hospital in Rochester, Minn., says each HBIPS measure is composed of sub-elements. For example, the assessment measure includes admission screening for violence risk, substance abuse, trauma history, and patient strengths, such as motivation and family involvement. These elements create a more complete picture of the patient and might improve the initial assessment. By improving initial assessment, experts in the field hope hospital staff will be able to better identify problems, Dr. Lineberry says.

“We are all working for improvement in care,” says Dr. Lineberry, noting the Mayo Clinic was one of the pilot sites. “HBIPS is part of that effort.”

Time Is of the Essence

Many of the standards represent areas in which there is consensus among psychiatrists about the need for change, says Anand Pandya, MD, a psychiatric hospitalist and director of inpatient psychiatry at Cedars-Sinai Medical Center in Los Angeles. Many psychiatrists recognize there is a need to improve communication between inpatient psychiatric services and follow-up outpatient providers, Dr. Pandya says. However, a clear consensus has not been reached regarding the standards of tracking patients who take multiple antipsychotic medications, Dr. Pandya says.

“With the low average length of stay in inpatient psychiatric units, it is common for patients to continue a cross-taper between medications after discharge,” Dr. Pandya says. “For most antipsychotic medications, there is insufficient data to determine how fast or slow to cross-taper. I worry that these standards may send the unintentional message that these cross-tapers should be completed quickly during the course of a brief inpatient stay.”

Data suggest individuals using lithium should be tapered off the drug as slowly as possible—probably over months rather than weeks, Dr. Pandya says. “I am concerned that tracking data regarding patients on multiple antipsychotic medications may create incentives to change practice in a sub-optimal direction for some cases,” he says.

Dr. Duckworth also acknowledges patients’ length of stay is getting shorter. Psychiatric hospitalists are under a great deal of pressure to “get people patched up in too short a period of time,” he says. “They really do need more time. There is a temptation to use more than one antipsychotic medication, but people really should not be given two antipsychotic medications unless someone has performed a thoughtful assessment.”

On Board with HBIPS

While HBIPS covers areas of care important to many, the details of implementing the measure set might be challenging, Dr. Lineberry says. The requirements increase the documentation burden for physicians, nurses, and allied health professionals, such as social workers and therapists. Hospitals using electronic medical records might have to modify their records to meet the requirements. And with the new measure comes new, significant personnel costs to audit and collect the data, he says.

“For psychiatric hospitalists who are using HBIPS, it will be helpful to look at the measures from a multidisciplinary standpoint,” Dr. Lineberry says. “Approach HBIPS as a team. Look at the process and see how it works, then adapt it to fit in with your current workflow.”

As of July, more than 274 psychiatric hospitals and psychiatric units had implemented the HBIPS measures. “We don’t usually have numbers until at least six months after,” Milton says, noting the commission is eager to receive quantitative data and report back to the participating hospitals.

Milton anticipates the Joint Commission will submit the HBIPS measure set to the National Quality Forum (NQF) for consideration and endorsement. Although she anticipates the measures will receive NQF endorsement sometime this year, an exact timeline has not been established, she says. The Joint Commission will work closely with the NQF to ensure the HBIPS measure set receives endorsement, and will make necessary modifications that may be required, Milton says.

Once HBIPS receives NQF endorsement, HBIPS data will be publicly reported following the first two quarters of data collection, Milton says. Data on each hospital will be available at www.qualitycheck.org. TH

Gina Gotsill is a freelance medical writer in California. Freelance writer Chris Haliskoe contributed to this report.

Image Source: TIM TEEBKEN/PHOTODISC

Sunil Kripalani, MD, MSc, chief of hospital medicine at Vanderbilt University in Nashville, Tenn., was working in the emergency department when a woman arrived with an asthma exacerbation. The woman, who spoke only Spanish, had been hospitalized just five days earlier for asthma, and hospital staff had given her discharge instructions through her husband. Speaking to the patient in Spanish, Dr. Kripalani soon learned something had been lost in translation: The patient had not taken any of the prescribed prednisone tablets, and instead was taking a burst of montelukast. She also was taking a long-acting bronchodilator every two hours instead of every 12, and she was incorrectly using her rescue inhaler.

As the principal investigator of a trial aiming to reduce post-discharge adverse events and emergency room visits, Dr. Kripalani knows well the issues that contributed to the patient’s re-hospitalization.1 Through research, he and his colleagues hope to prevent future cases.

“It’s very rewarding to identify problems in the care of hospitalized patients and then develop and evaluate interventions to solve those problems,” says Dr. Kripalani, a 2001 graduate of the Emory Mentored Clinical Research Scholars Program who also leads Vanderbilt University’s hospital medicine fellowship. “Sharing those solutions with colleagues so they can be applied to patient care at my institution and others brings the research full circle.”

As the field of hospital medicine grows, the number of hospitalists moving into research careers is expanding, says Peter Kaboli, MD, MS, associate professor in the Department of Internal Medicine at the University of Iowa and a 2001 graduate of the Veterans Administration Quality Scholars Fellowship program. Research training programs, or fellowships, put hospitalists on the path to new skills and position them for careers in academic medicine and other leadership positions, Dr. Kaboli says. Training programs also put fellows in contact with mentors who provide valuable guidance.

Although there are dozens of general internal medicine (GIM) fellowships available to hospitalists, few programs are specifically designed to train hospitalists in research. “Hospital medicine is still a relatively new field,” Dr. Kaboli explains. “The field still does not have many research training options that are separate from general internal medicine.”

Still, hospitalists have advanced training choices, and, depending on their interests, can pursue field-specific programs or follow a general internal medicine path.

HOSPITAL RESEARCH: WHERE THE HEART IS

Are you considering a research training program? Dr. Brotman recommends physicians consider the following before starting their search.

• If you want to work as a hospitalist in an academic center or you want to be a clinical leader, and you want to participate in research but you don’t anticipate committing the majority of your time to research, then many of the programs listed on SHM’s Web site (www.hospitalmedicine.org) could be useful.
• If you want to spend the bulk of your time performing research, the best programs will be focused on research and allow you to devote at least 50% of your time to research training.

Here are a couple of questions to ask yourself as you narrow your fellowship search:

Q: Will this fellowship lead to an advanced degree?

A: The statistical and methodological training provided by a master’s or PhD degree curriculum will provide the fellow with many of the tools needed to successfully compete for research funding as a faculty member in an academic center.

Q: What kind of research is expected?

A: Most programs encourage fellows to do some research, but if it is a formal expectation rather than an opportunity, it is likely that there will be a greater faculty and program commitment to research. This ensures the fellow leaves the program having completed a research program and, ideally, publishing on it.—GG

Career Investment

Many hospitalists receive basic research training from GIM fellowships. Once they have a research foundation, they can take their experience in another direction.

“Some physicians use their clinical interest—hospital medicine—as the platform for their research,” Dr. Kaboli says, using his own resume as an example. “It’s a nice synergy—doing research in a clinical area of interest.”

Physicians interested in fellowships often start looking for opportunities before they complete their residency, or immediately after. The transition makes sense for some; they move from one academic setting to another. Others, however, consider fellowship programs after they have spent some time in practice and get what Dr. Kaboli calls “boots-on-the-ground experience.”

“I think this is an area where there is potential for growth,” Dr. Kaboli says of physicians returning to fellowship programs after years spent in practice. “It’s the equivalent of a businessperson going back to school to get an MBA. They say, ‘Now I understand what this job really means, and I want to do more.’ ”

The caveat is a pay cut. Physicians in fellowship programs generally are paid a stipend of about $50,000 a year, Kaboli says. By comparison, the average hospitalist makes about $193,000 per year, according to SHM’s 2007-2008 Bi-Annual Survey on the State of Hospital Medicine. For two years, fellows devote their lives to training, coursework, and research, and spend only about 25% of their time treating patients, he says.

Road to Research

Hospitalists can choose from a range of general internal medicine fellowships at universities, clinics, and medical centers across the country. Each program offers something different; the fit depends on the candidates’ interests, says Geri Barnes, SHM senior director of education and meetings. For instance, training programs offer advanced study in the areas of biostatistics, epidemiology, and research methodology, to name a few. GIM fellowships (see “To Be or Not to Be a Fellow,” May 2006, p. 26) encourage scholars to develop relationships with mentors to guide them through research projects, she explains. A program’s duration can span one to three years. Some programs give fellows the opportunity to earn an advanced degree in quality improvement, clinical research, public policy, health studies, public health, or clinical epidemiology.

A handful of institutions, including Johns Hopkins Hospital in Baltimore, offer GIM fellowships with a hospital medicine emphasis. The National Institutes of Health (NIH) funds the Johns Hopkins program with training grants, says Daniel J. Brotman, MD, director of the hospitalist program there. GIM leadership is taking a “big tent” approach, promoting the development of hospital medicine tracks within the full program, which is good for the fellowship and for the hospitalist program, Dr. Brotman says.

“Some of the challenges for hospitalists are that they are generally young and don’t have the skills to succeed in academic medicine,” Dr. Brotman says, “and the number of mentors in hospitalist medicine is few and far between. [The fellowship] allows scholars to tap into experienced research mentors who may not be hospitalists themselves but are interested in investigating research questions and promoting academic careers in hospitalist medicine.”

The GIM program at Johns Hopkins draws physicians trained in internal medicine as well as general medicine/pediatrics. Candidates are required to have completed an internal medicine or medicine/pediatrics residency and must provide strong letters of recommendation. Scholars receive training in statistical methods while obtaining a master’s degree in public health or health science at the Johns Hopkins Bloomberg School of Public Health. Fellows commit 80% of their time to research and research training, and 20% of their time to clinical duties; they are expected to form relationships with faculty, which ultimately leads to careers in academia or public health, Dr. Brotman explains.

Minimize Burnout

Physician burnout—so common in the current healthcare system—is an excellent reason to consider a research career. Five years ago, David Meltzer, MD, PhD, an associate professor in the Department of Medicine at the University of Chicago, wanted to increase the number of research-trained hospitalists, so he moved to create a hospitalist training program. Around the same time, the hospital approached Dr. Meltzer and others, asking them to expand the number of clinical physician positions.

“We were afraid the new physicians would burn out rather quickly if their jobs included only clinical work,” Dr. Meltzer says. “We designed positions that had less clinical work but more time for physicians to develop research skills to support sustainable academic careers.”

Hospital leaders agreed, and the university’s Hospitalist Scholars Training Program was born. The two-year curriculum trains hospitalists for a career in academic research, and combines inpatient clinical work, coursework, and mentored training related to an academic project. Scholars typically leave the program with a master’s degree in public policy or health studies.

“Most of our graduates are working in academic research,” Dr. Meltzer says. “The program has been a great source of new faculty for us.”

Short-term programs are available in select topics. For example, the University of Chicago offers a summer program in outcomes research training for hospitalists interested in careers in health research, Dr. Meltzer says. SHM and the Agency for Healthcare Research and Quality have provided funding to expand the program to include as many as six hospitalists from around the country.

Pioneer Program

Applicants from any medical or surgical specialty are eligible to apply for the Robert Wood Johnson (RWJ) Clinical Scholars Program, the nation’s oldest research training program for physicians in health services, research, and leadership.

“The mandate of Robert Wood Johnson is ‘health and healthcare for all Americans,’ ” says Desmond Runyan, MD, DrPH, national program director of the RWJ Clinical Scholars Program. “We give physicians the skills they need to be leaders, and then we push them out the door so they can go out and shape the future of healthcare in this country.”

Applicants must be U.S. citizens and, with the exception of surgeons, must complete their residency training before entering the clinical scholars program. The two-year program offers a master’s degree in graduate-level study and research, and scholars may be considered for a third year of support. Scholars have their choice of four training sites: the University of California at Los Angeles; Yale University in New Haven, Conn.; the University of Pennsylvania in Philadelphia; or the University of Michigan in Ann Arbor.

Programs vary, but each university has a curriculum to teach the basics of healthcare research. It also provides protected time for research; about 20% of time is spent on clinical activities, according to the program’s Web site. Graduates receive leadership, health services, and community-based research training.

The RWJ Foundation spends about $9 million per year on the program, which covers research support, salaries for scholars and program administrators, travel, and other expenses. About half of the program’s graduates go into academic positions; the other half go into public health or other leadership positions. One recent graduate opted for a position in quality control; three other graduates serve as staff in the U.S. House of Representatives and the U.S. Senate, he says. Other graduates work with foundations, state and federal health agencies, or with companies working in the healthcare industry.

“This program looks for people who don’t march to a standard drummer,” Dr. Runyon says. “We are looking for risk-takers who want to make a difference.”

VA Training

The Veterans Administration National Quality Scholars Fellowship Program (VAQS) welcomes physicians from all medical specialties, including pathology, OB/GYN, surgery, and dermatology. This year, the program will begin recruiting nurses.

The program is offered at six academic-affiliated VA medical centers: Iowa City, Iowa; Nashville, Tenn.; Birmingham, Ala.; Cleveland; San Francisco; and White River Junction, Vt. The Iowa City and Nashville programs have a track designed specifically for hospitalists. These tracks focus on clinical research and quality improvement work in the inpatient setting, and provide fellows with training for advancement in academic and private-sector hospitalist careers, says Dr. Kaboli, the Iowa City VAQS Fellowship director.

To qualify, fellowship applicants must have completed an Accreditation Council for Graduate Medical Education residency or fellowship (see “A Pregnant Pause: The necessary evolution of residency training,” January 2007, p. 35), be board-eligible or board-certified, and have an active, unrestricted U.S. license to practice. International graduates must meet visa and Educational Commission for Foreign Medical Graduates requirements.

The two-year VAQS focuses on quality improvement in healthcare, Dr. Kaboli says. The program offers master’s-level training in epidemiology and biostatistics, and trains fellows to design and conduct research and improvement projects. Fellows publish the results of their research in peer-reviewed journals. They also learn how to write grants to gain funding for future projects.

Mentoring is an important element of the VAQS program, Dr. Kaboli says, adding that the value a trainee receives from any fellowship depends on the level of mentoring available through the program. Fellows work with senior faculty members who provide guidance on all aspects of research, Dr. Kaboli says. This includes study design, research methodology, data collection and analyses, and writing.

New experiences and the opportunity to take part in research are among the benefits of completing the VAQS program, Dr. Kaboli says. Some physicians also find a great deal of career satisfaction through research.

“I love seeing patients,” Dr. Kaboli says, “but I also like the challenge of doing research to find new ways to improve patient care.” TH

Gina Gotsill is a freelance medical writer based in California.

Reference

1. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowship: works in progress. Am J Med. 2006;119;72.e1-72.e7.

Sunil Kripalani, MD, MSc, chief of hospital medicine at Vanderbilt University in Nashville, Tenn., was working in the emergency department when a woman arrived with an asthma exacerbation. The woman, who spoke only Spanish, had been hospitalized just five days earlier for asthma, and hospital staff had given her discharge instructions through her husband. Speaking to the patient in Spanish, Dr. Kripalani soon learned something had been lost in translation: The patient had not taken any of the prescribed prednisone tablets, and instead was taking a burst of montelukast. She also was taking a long-acting bronchodilator every two hours instead of every 12, and she was incorrectly using her rescue inhaler.

As the principal investigator of a trial aiming to reduce post-discharge adverse events and emergency room visits, Dr. Kripalani knows well the issues that contributed to the patient’s re-hospitalization.1 Through research, he and his colleagues hope to prevent future cases.

“It’s very rewarding to identify problems in the care of hospitalized patients and then develop and evaluate interventions to solve those problems,” says Dr. Kripalani, a 2001 graduate of the Emory Mentored Clinical Research Scholars Program who also leads Vanderbilt University’s hospital medicine fellowship. “Sharing those solutions with colleagues so they can be applied to patient care at my institution and others brings the research full circle.”

As the field of hospital medicine grows, the number of hospitalists moving into research careers is expanding, says Peter Kaboli, MD, MS, associate professor in the Department of Internal Medicine at the University of Iowa and a 2001 graduate of the Veterans Administration Quality Scholars Fellowship program. Research training programs, or fellowships, put hospitalists on the path to new skills and position them for careers in academic medicine and other leadership positions, Dr. Kaboli says. Training programs also put fellows in contact with mentors who provide valuable guidance.

Although there are dozens of general internal medicine (GIM) fellowships available to hospitalists, few programs are specifically designed to train hospitalists in research. “Hospital medicine is still a relatively new field,” Dr. Kaboli explains. “The field still does not have many research training options that are separate from general internal medicine.”

Still, hospitalists have advanced training choices, and, depending on their interests, can pursue field-specific programs or follow a general internal medicine path.

HOSPITAL RESEARCH: WHERE THE HEART IS

Are you considering a research training program? Dr. Brotman recommends physicians consider the following before starting their search.

• If you want to work as a hospitalist in an academic center or you want to be a clinical leader, and you want to participate in research but you don’t anticipate committing the majority of your time to research, then many of the programs listed on SHM’s Web site (www.hospitalmedicine.org) could be useful.
• If you want to spend the bulk of your time performing research, the best programs will be focused on research and allow you to devote at least 50% of your time to research training.

Here are a couple of questions to ask yourself as you narrow your fellowship search:

Q: Will this fellowship lead to an advanced degree?

A: The statistical and methodological training provided by a master’s or PhD degree curriculum will provide the fellow with many of the tools needed to successfully compete for research funding as a faculty member in an academic center.

Q: What kind of research is expected?

A: Most programs encourage fellows to do some research, but if it is a formal expectation rather than an opportunity, it is likely that there will be a greater faculty and program commitment to research. This ensures the fellow leaves the program having completed a research program and, ideally, publishing on it.—GG

Career Investment

Many hospitalists receive basic research training from GIM fellowships. Once they have a research foundation, they can take their experience in another direction.

“Some physicians use their clinical interest—hospital medicine—as the platform for their research,” Dr. Kaboli says, using his own resume as an example. “It’s a nice synergy—doing research in a clinical area of interest.”

Physicians interested in fellowships often start looking for opportunities before they complete their residency, or immediately after. The transition makes sense for some; they move from one academic setting to another. Others, however, consider fellowship programs after they have spent some time in practice and get what Dr. Kaboli calls “boots-on-the-ground experience.”

“I think this is an area where there is potential for growth,” Dr. Kaboli says of physicians returning to fellowship programs after years spent in practice. “It’s the equivalent of a businessperson going back to school to get an MBA. They say, ‘Now I understand what this job really means, and I want to do more.’ ”

The caveat is a pay cut. Physicians in fellowship programs generally are paid a stipend of about $50,000 a year, Kaboli says. By comparison, the average hospitalist makes about $193,000 per year, according to SHM’s 2007-2008 Bi-Annual Survey on the State of Hospital Medicine. For two years, fellows devote their lives to training, coursework, and research, and spend only about 25% of their time treating patients, he says.

Road to Research

Hospitalists can choose from a range of general internal medicine fellowships at universities, clinics, and medical centers across the country. Each program offers something different; the fit depends on the candidates’ interests, says Geri Barnes, SHM senior director of education and meetings. For instance, training programs offer advanced study in the areas of biostatistics, epidemiology, and research methodology, to name a few. GIM fellowships (see “To Be or Not to Be a Fellow,” May 2006, p. 26) encourage scholars to develop relationships with mentors to guide them through research projects, she explains. A program’s duration can span one to three years. Some programs give fellows the opportunity to earn an advanced degree in quality improvement, clinical research, public policy, health studies, public health, or clinical epidemiology.

A handful of institutions, including Johns Hopkins Hospital in Baltimore, offer GIM fellowships with a hospital medicine emphasis. The National Institutes of Health (NIH) funds the Johns Hopkins program with training grants, says Daniel J. Brotman, MD, director of the hospitalist program there. GIM leadership is taking a “big tent” approach, promoting the development of hospital medicine tracks within the full program, which is good for the fellowship and for the hospitalist program, Dr. Brotman says.

“Some of the challenges for hospitalists are that they are generally young and don’t have the skills to succeed in academic medicine,” Dr. Brotman says, “and the number of mentors in hospitalist medicine is few and far between. [The fellowship] allows scholars to tap into experienced research mentors who may not be hospitalists themselves but are interested in investigating research questions and promoting academic careers in hospitalist medicine.”

The GIM program at Johns Hopkins draws physicians trained in internal medicine as well as general medicine/pediatrics. Candidates are required to have completed an internal medicine or medicine/pediatrics residency and must provide strong letters of recommendation. Scholars receive training in statistical methods while obtaining a master’s degree in public health or health science at the Johns Hopkins Bloomberg School of Public Health. Fellows commit 80% of their time to research and research training, and 20% of their time to clinical duties; they are expected to form relationships with faculty, which ultimately leads to careers in academia or public health, Dr. Brotman explains.

Minimize Burnout

Physician burnout—so common in the current healthcare system—is an excellent reason to consider a research career. Five years ago, David Meltzer, MD, PhD, an associate professor in the Department of Medicine at the University of Chicago, wanted to increase the number of research-trained hospitalists, so he moved to create a hospitalist training program. Around the same time, the hospital approached Dr. Meltzer and others, asking them to expand the number of clinical physician positions.

“We were afraid the new physicians would burn out rather quickly if their jobs included only clinical work,” Dr. Meltzer says. “We designed positions that had less clinical work but more time for physicians to develop research skills to support sustainable academic careers.”

Hospital leaders agreed, and the university’s Hospitalist Scholars Training Program was born. The two-year curriculum trains hospitalists for a career in academic research, and combines inpatient clinical work, coursework, and mentored training related to an academic project. Scholars typically leave the program with a master’s degree in public policy or health studies.

“Most of our graduates are working in academic research,” Dr. Meltzer says. “The program has been a great source of new faculty for us.”

Short-term programs are available in select topics. For example, the University of Chicago offers a summer program in outcomes research training for hospitalists interested in careers in health research, Dr. Meltzer says. SHM and the Agency for Healthcare Research and Quality have provided funding to expand the program to include as many as six hospitalists from around the country.

Pioneer Program

Applicants from any medical or surgical specialty are eligible to apply for the Robert Wood Johnson (RWJ) Clinical Scholars Program, the nation’s oldest research training program for physicians in health services, research, and leadership.

“The mandate of Robert Wood Johnson is ‘health and healthcare for all Americans,’ ” says Desmond Runyan, MD, DrPH, national program director of the RWJ Clinical Scholars Program. “We give physicians the skills they need to be leaders, and then we push them out the door so they can go out and shape the future of healthcare in this country.”

Applicants must be U.S. citizens and, with the exception of surgeons, must complete their residency training before entering the clinical scholars program. The two-year program offers a master’s degree in graduate-level study and research, and scholars may be considered for a third year of support. Scholars have their choice of four training sites: the University of California at Los Angeles; Yale University in New Haven, Conn.; the University of Pennsylvania in Philadelphia; or the University of Michigan in Ann Arbor.

Programs vary, but each university has a curriculum to teach the basics of healthcare research. It also provides protected time for research; about 20% of time is spent on clinical activities, according to the program’s Web site. Graduates receive leadership, health services, and community-based research training.

The RWJ Foundation spends about $9 million per year on the program, which covers research support, salaries for scholars and program administrators, travel, and other expenses. About half of the program’s graduates go into academic positions; the other half go into public health or other leadership positions. One recent graduate opted for a position in quality control; three other graduates serve as staff in the U.S. House of Representatives and the U.S. Senate, he says. Other graduates work with foundations, state and federal health agencies, or with companies working in the healthcare industry.

“This program looks for people who don’t march to a standard drummer,” Dr. Runyon says. “We are looking for risk-takers who want to make a difference.”

VA Training

The Veterans Administration National Quality Scholars Fellowship Program (VAQS) welcomes physicians from all medical specialties, including pathology, OB/GYN, surgery, and dermatology. This year, the program will begin recruiting nurses.

The program is offered at six academic-affiliated VA medical centers: Iowa City, Iowa; Nashville, Tenn.; Birmingham, Ala.; Cleveland; San Francisco; and White River Junction, Vt. The Iowa City and Nashville programs have a track designed specifically for hospitalists. These tracks focus on clinical research and quality improvement work in the inpatient setting, and provide fellows with training for advancement in academic and private-sector hospitalist careers, says Dr. Kaboli, the Iowa City VAQS Fellowship director.

To qualify, fellowship applicants must have completed an Accreditation Council for Graduate Medical Education residency or fellowship (see “A Pregnant Pause: The necessary evolution of residency training,” January 2007, p. 35), be board-eligible or board-certified, and have an active, unrestricted U.S. license to practice. International graduates must meet visa and Educational Commission for Foreign Medical Graduates requirements.

The two-year VAQS focuses on quality improvement in healthcare, Dr. Kaboli says. The program offers master’s-level training in epidemiology and biostatistics, and trains fellows to design and conduct research and improvement projects. Fellows publish the results of their research in peer-reviewed journals. They also learn how to write grants to gain funding for future projects.

Mentoring is an important element of the VAQS program, Dr. Kaboli says, adding that the value a trainee receives from any fellowship depends on the level of mentoring available through the program. Fellows work with senior faculty members who provide guidance on all aspects of research, Dr. Kaboli says. This includes study design, research methodology, data collection and analyses, and writing.

New experiences and the opportunity to take part in research are among the benefits of completing the VAQS program, Dr. Kaboli says. Some physicians also find a great deal of career satisfaction through research.

“I love seeing patients,” Dr. Kaboli says, “but I also like the challenge of doing research to find new ways to improve patient care.” TH

Gina Gotsill is a freelance medical writer based in California.

Reference

1. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowship: works in progress. Am J Med. 2006;119;72.e1-72.e7.

Sunil Kripalani, MD, MSc, chief of hospital medicine at Vanderbilt University in Nashville, Tenn., was working in the emergency department when a woman arrived with an asthma exacerbation. The woman, who spoke only Spanish, had been hospitalized just five days earlier for asthma, and hospital staff had given her discharge instructions through her husband. Speaking to the patient in Spanish, Dr. Kripalani soon learned something had been lost in translation: The patient had not taken any of the prescribed prednisone tablets, and instead was taking a burst of montelukast. She also was taking a long-acting bronchodilator every two hours instead of every 12, and she was incorrectly using her rescue inhaler.

As the principal investigator of a trial aiming to reduce post-discharge adverse events and emergency room visits, Dr. Kripalani knows well the issues that contributed to the patient’s re-hospitalization.1 Through research, he and his colleagues hope to prevent future cases.

“It’s very rewarding to identify problems in the care of hospitalized patients and then develop and evaluate interventions to solve those problems,” says Dr. Kripalani, a 2001 graduate of the Emory Mentored Clinical Research Scholars Program who also leads Vanderbilt University’s hospital medicine fellowship. “Sharing those solutions with colleagues so they can be applied to patient care at my institution and others brings the research full circle.”

As the field of hospital medicine grows, the number of hospitalists moving into research careers is expanding, says Peter Kaboli, MD, MS, associate professor in the Department of Internal Medicine at the University of Iowa and a 2001 graduate of the Veterans Administration Quality Scholars Fellowship program. Research training programs, or fellowships, put hospitalists on the path to new skills and position them for careers in academic medicine and other leadership positions, Dr. Kaboli says. Training programs also put fellows in contact with mentors who provide valuable guidance.

Although there are dozens of general internal medicine (GIM) fellowships available to hospitalists, few programs are specifically designed to train hospitalists in research. “Hospital medicine is still a relatively new field,” Dr. Kaboli explains. “The field still does not have many research training options that are separate from general internal medicine.”

Still, hospitalists have advanced training choices, and, depending on their interests, can pursue field-specific programs or follow a general internal medicine path.

HOSPITAL RESEARCH: WHERE THE HEART IS

Are you considering a research training program? Dr. Brotman recommends physicians consider the following before starting their search.

• If you want to work as a hospitalist in an academic center or you want to be a clinical leader, and you want to participate in research but you don’t anticipate committing the majority of your time to research, then many of the programs listed on SHM’s Web site (www.hospitalmedicine.org) could be useful.
• If you want to spend the bulk of your time performing research, the best programs will be focused on research and allow you to devote at least 50% of your time to research training.

Here are a couple of questions to ask yourself as you narrow your fellowship search:

Q: Will this fellowship lead to an advanced degree?

A: The statistical and methodological training provided by a master’s or PhD degree curriculum will provide the fellow with many of the tools needed to successfully compete for research funding as a faculty member in an academic center.

Q: What kind of research is expected?

A: Most programs encourage fellows to do some research, but if it is a formal expectation rather than an opportunity, it is likely that there will be a greater faculty and program commitment to research. This ensures the fellow leaves the program having completed a research program and, ideally, publishing on it.—GG

Career Investment

Many hospitalists receive basic research training from GIM fellowships. Once they have a research foundation, they can take their experience in another direction.

“Some physicians use their clinical interest—hospital medicine—as the platform for their research,” Dr. Kaboli says, using his own resume as an example. “It’s a nice synergy—doing research in a clinical area of interest.”

Physicians interested in fellowships often start looking for opportunities before they complete their residency, or immediately after. The transition makes sense for some; they move from one academic setting to another. Others, however, consider fellowship programs after they have spent some time in practice and get what Dr. Kaboli calls “boots-on-the-ground experience.”

“I think this is an area where there is potential for growth,” Dr. Kaboli says of physicians returning to fellowship programs after years spent in practice. “It’s the equivalent of a businessperson going back to school to get an MBA. They say, ‘Now I understand what this job really means, and I want to do more.’ ”

The caveat is a pay cut. Physicians in fellowship programs generally are paid a stipend of about $50,000 a year, Kaboli says. By comparison, the average hospitalist makes about $193,000 per year, according to SHM’s 2007-2008 Bi-Annual Survey on the State of Hospital Medicine. For two years, fellows devote their lives to training, coursework, and research, and spend only about 25% of their time treating patients, he says.

Road to Research

Hospitalists can choose from a range of general internal medicine fellowships at universities, clinics, and medical centers across the country. Each program offers something different; the fit depends on the candidates’ interests, says Geri Barnes, SHM senior director of education and meetings. For instance, training programs offer advanced study in the areas of biostatistics, epidemiology, and research methodology, to name a few. GIM fellowships (see “To Be or Not to Be a Fellow,” May 2006, p. 26) encourage scholars to develop relationships with mentors to guide them through research projects, she explains. A program’s duration can span one to three years. Some programs give fellows the opportunity to earn an advanced degree in quality improvement, clinical research, public policy, health studies, public health, or clinical epidemiology.

A handful of institutions, including Johns Hopkins Hospital in Baltimore, offer GIM fellowships with a hospital medicine emphasis. The National Institutes of Health (NIH) funds the Johns Hopkins program with training grants, says Daniel J. Brotman, MD, director of the hospitalist program there. GIM leadership is taking a “big tent” approach, promoting the development of hospital medicine tracks within the full program, which is good for the fellowship and for the hospitalist program, Dr. Brotman says.

“Some of the challenges for hospitalists are that they are generally young and don’t have the skills to succeed in academic medicine,” Dr. Brotman says, “and the number of mentors in hospitalist medicine is few and far between. [The fellowship] allows scholars to tap into experienced research mentors who may not be hospitalists themselves but are interested in investigating research questions and promoting academic careers in hospitalist medicine.”

The GIM program at Johns Hopkins draws physicians trained in internal medicine as well as general medicine/pediatrics. Candidates are required to have completed an internal medicine or medicine/pediatrics residency and must provide strong letters of recommendation. Scholars receive training in statistical methods while obtaining a master’s degree in public health or health science at the Johns Hopkins Bloomberg School of Public Health. Fellows commit 80% of their time to research and research training, and 20% of their time to clinical duties; they are expected to form relationships with faculty, which ultimately leads to careers in academia or public health, Dr. Brotman explains.

Minimize Burnout

Physician burnout—so common in the current healthcare system—is an excellent reason to consider a research career. Five years ago, David Meltzer, MD, PhD, an associate professor in the Department of Medicine at the University of Chicago, wanted to increase the number of research-trained hospitalists, so he moved to create a hospitalist training program. Around the same time, the hospital approached Dr. Meltzer and others, asking them to expand the number of clinical physician positions.

“We were afraid the new physicians would burn out rather quickly if their jobs included only clinical work,” Dr. Meltzer says. “We designed positions that had less clinical work but more time for physicians to develop research skills to support sustainable academic careers.”

Hospital leaders agreed, and the university’s Hospitalist Scholars Training Program was born. The two-year curriculum trains hospitalists for a career in academic research, and combines inpatient clinical work, coursework, and mentored training related to an academic project. Scholars typically leave the program with a master’s degree in public policy or health studies.

“Most of our graduates are working in academic research,” Dr. Meltzer says. “The program has been a great source of new faculty for us.”

Short-term programs are available in select topics. For example, the University of Chicago offers a summer program in outcomes research training for hospitalists interested in careers in health research, Dr. Meltzer says. SHM and the Agency for Healthcare Research and Quality have provided funding to expand the program to include as many as six hospitalists from around the country.

Pioneer Program

Applicants from any medical or surgical specialty are eligible to apply for the Robert Wood Johnson (RWJ) Clinical Scholars Program, the nation’s oldest research training program for physicians in health services, research, and leadership.

“The mandate of Robert Wood Johnson is ‘health and healthcare for all Americans,’ ” says Desmond Runyan, MD, DrPH, national program director of the RWJ Clinical Scholars Program. “We give physicians the skills they need to be leaders, and then we push them out the door so they can go out and shape the future of healthcare in this country.”

Applicants must be U.S. citizens and, with the exception of surgeons, must complete their residency training before entering the clinical scholars program. The two-year program offers a master’s degree in graduate-level study and research, and scholars may be considered for a third year of support. Scholars have their choice of four training sites: the University of California at Los Angeles; Yale University in New Haven, Conn.; the University of Pennsylvania in Philadelphia; or the University of Michigan in Ann Arbor.

Programs vary, but each university has a curriculum to teach the basics of healthcare research. It also provides protected time for research; about 20% of time is spent on clinical activities, according to the program’s Web site. Graduates receive leadership, health services, and community-based research training.

The RWJ Foundation spends about $9 million per year on the program, which covers research support, salaries for scholars and program administrators, travel, and other expenses. About half of the program’s graduates go into academic positions; the other half go into public health or other leadership positions. One recent graduate opted for a position in quality control; three other graduates serve as staff in the U.S. House of Representatives and the U.S. Senate, he says. Other graduates work with foundations, state and federal health agencies, or with companies working in the healthcare industry.

“This program looks for people who don’t march to a standard drummer,” Dr. Runyon says. “We are looking for risk-takers who want to make a difference.”

VA Training

The Veterans Administration National Quality Scholars Fellowship Program (VAQS) welcomes physicians from all medical specialties, including pathology, OB/GYN, surgery, and dermatology. This year, the program will begin recruiting nurses.

The program is offered at six academic-affiliated VA medical centers: Iowa City, Iowa; Nashville, Tenn.; Birmingham, Ala.; Cleveland; San Francisco; and White River Junction, Vt. The Iowa City and Nashville programs have a track designed specifically for hospitalists. These tracks focus on clinical research and quality improvement work in the inpatient setting, and provide fellows with training for advancement in academic and private-sector hospitalist careers, says Dr. Kaboli, the Iowa City VAQS Fellowship director.

To qualify, fellowship applicants must have completed an Accreditation Council for Graduate Medical Education residency or fellowship (see “A Pregnant Pause: The necessary evolution of residency training,” January 2007, p. 35), be board-eligible or board-certified, and have an active, unrestricted U.S. license to practice. International graduates must meet visa and Educational Commission for Foreign Medical Graduates requirements.

The two-year VAQS focuses on quality improvement in healthcare, Dr. Kaboli says. The program offers master’s-level training in epidemiology and biostatistics, and trains fellows to design and conduct research and improvement projects. Fellows publish the results of their research in peer-reviewed journals. They also learn how to write grants to gain funding for future projects.

Mentoring is an important element of the VAQS program, Dr. Kaboli says, adding that the value a trainee receives from any fellowship depends on the level of mentoring available through the program. Fellows work with senior faculty members who provide guidance on all aspects of research, Dr. Kaboli says. This includes study design, research methodology, data collection and analyses, and writing.

New experiences and the opportunity to take part in research are among the benefits of completing the VAQS program, Dr. Kaboli says. Some physicians also find a great deal of career satisfaction through research.

“I love seeing patients,” Dr. Kaboli says, “but I also like the challenge of doing research to find new ways to improve patient care.” TH

Gina Gotsill is a freelance medical writer based in California.

Reference

1. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowship: works in progress. Am J Med. 2006;119;72.e1-72.e7.

Sharnjit Grewal, MD, a hospitalist at Mercy Medical Group in Sacramento, Calif., is familiar with what he calls “the double-take.” A Sikh born and raised in California, Dr. Grewal wears a traditional turban and full beard. When he walks into the room, some patient’s simply don’t know what to make of him, he admits.

“It’s confusing—even to my Hindu and Sikh patients,” Dr. Grewal says. “They sometimes say, ‘You talk like an American, you’re obviously from the West, but you follow a faith from the East. The line between religion and culture is obscured.”

Although the medical community stresses cultural awareness and sensitivity, Dr. Grewal’s experience highlights the fine line between religion and culture, and the barriers standing stand in the way of cultural awareness.

Today, hospitals experience shifting patient demographics and a growing number of languages and dialects observed in the United States today. Between 1990-2000, the foreign-born population in the U.S. increased by 57%, compared with a 9.3% increase for the native population and a 13% increase for the total U.S. population, according to the U.S. Census Bureau.

Break Down Walls

When hospitalists and patients share a culture or language, the result can be extremely positive. In fact, the Joint Commission report states some hospitals in the United States are working to increase racial and ethnic similarities between staff and patient populations.

Joseph Li, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston, frequently works with Cantonese-speaking patients referred to the hospital by the healthcare clinic in Boston’s Chinatown section. When he greets patients in their native tongue, Dr. Li says he can feel their comfort level rise; even though he speaks what he calls “5-year-old Cantonese.”

“There is an improved therapeutic relationship when doctors and patients share a language, culture, or belief,” Dr. Li says. “There’s a level of comfort that you are going to be understood and nothing will be lost in translation.”

A patient’s culture may drive decisions contradictory to traditional Western medicine, and hospitalists need to make the time to listen and respond. Recently, Dr. Grewal treated a dying, elderly Asian patient whose family insisted on administering an unknown, water-like fluid to cure the loved one. First, the family requested giving the fluid to the patient by mouth. Dr. Grewal denied the request, and told them the water would end up in the patient’s lungs because he was comatose and could not swallow. Then, the family asked if they could add it to the intravenous line. Again, Dr. Grewal denied the request, and told them water in an un-buffered solution could be harmful to red blood cells.

“It was frustrating for them,” Dr. Grewal says. “I told them, ‘It’s not that I don’t believe the water will cure him. Maybe it will or maybe it won’t. But from a medical standpoint, I know there will be complications and I just cannot do this.’ ”

Eventually, the family asked if a tube could be inserted into the patient’s stomach. When the request was denied, the family decided on comfort care for their loved one. Eventually, he passed away. The family, Dr. Grewal says, was grateful for the hospital staff’s care and effort, even though their requests to administer the fluid were denied.

Difficult Cases

Firm cultural beliefs may lead patients to resist treatment. Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in New Brunswick, N.J., recalls working with an elderly member of the Indian community who refused to be transferred to a rehabilitation facility. Dr. Patel took time to speak to the patient and learned she came from a tradition that encouraged younger generations to care for the elderly. The patient interpreted her transfer to a rehabilitation facility as a sign her family was abandoning her, Dr. Patel says.

“Sometimes you have to probe to learn more,” Dr. Patel says. “Once we understood her fears, we were able to convey to her that this was a temporary situation and that her family could not provide her with the services that she needed at that point in time.”

Dr. Patel also interacts with Hispanic and Indian patients—many of whom revere doctors and defer to them for treatment decisions. In these situations, he uses the same approach as he does with patients who question his treatment recommendations.

“The patient may defer to you, but it’s important to empower the patient and give them all the information they need to make major choices in their healthcare.”

Information Pipeline

Hospitalists may prefer to be upfront about a patient’s condition and treatment, however, cultural norms sometimes dictate who receives information—and how much. For example, Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif., says some Asian families prefer medical staff deliver bad news about the patient to them first. The family then decides what they will tell the patient, he says.

These situations create challenges and opportunities, Enderby says. Medical staff tries to establish a patient-centric care system, so it is important to continue appropriate communication with the patient. It also is important for healthcare providers to avoid putting the family in the middle and marginalizing the patient, he says. Healthcare teams can become frustrated when family members are at odds about decisions and options, and the patient is not involved at the family’s request, he says. In these cases, Dr. Enderby sees an opportunity to further engage the family, and, therefore, the patient.

“Often, when there are cultural and language barriers, a disengaged family can make caring for the patient very challenging,” Dr. Enderby says. “Having the family involved can help everyone feel more aligned with a treatment plan or strategy.”

For Alpesh Amin, MD, associate professor of medicine and vice chair for Clinical Affairs and Quality in the Department of Medicine at the University of California Irvine School of Medicine, being aware of a patient’s cultural values is critical to quality care. As executive director of the hospitalist program at the UCI Medical Center in Orange, Calif., Dr. Amin helped develop curriculum to train students on how to collect “values history” from patients, which includes asking questions about religion and culture. Students document their own values history, and then ask the same questions of a patient. Students discuss patient care and the importance of these histories during small group sessions.

“Knowing a patient's cultural information is just as important as knowing their sexual history or drug history,” Dr. Amin says. “It’s another piece of information that helps you get to know them as a whole. Their overall care is more comprehensive, if you have this knowledge.” TH

Gina Gotsill is a journalist based in California.

Sharnjit Grewal, MD, a hospitalist at Mercy Medical Group in Sacramento, Calif., is familiar with what he calls “the double-take.” A Sikh born and raised in California, Dr. Grewal wears a traditional turban and full beard. When he walks into the room, some patient’s simply don’t know what to make of him, he admits.

“It’s confusing—even to my Hindu and Sikh patients,” Dr. Grewal says. “They sometimes say, ‘You talk like an American, you’re obviously from the West, but you follow a faith from the East. The line between religion and culture is obscured.”

Although the medical community stresses cultural awareness and sensitivity, Dr. Grewal’s experience highlights the fine line between religion and culture, and the barriers standing stand in the way of cultural awareness.

Today, hospitals experience shifting patient demographics and a growing number of languages and dialects observed in the United States today. Between 1990-2000, the foreign-born population in the U.S. increased by 57%, compared with a 9.3% increase for the native population and a 13% increase for the total U.S. population, according to the U.S. Census Bureau.

Break Down Walls

When hospitalists and patients share a culture or language, the result can be extremely positive. In fact, the Joint Commission report states some hospitals in the United States are working to increase racial and ethnic similarities between staff and patient populations.

Joseph Li, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston, frequently works with Cantonese-speaking patients referred to the hospital by the healthcare clinic in Boston’s Chinatown section. When he greets patients in their native tongue, Dr. Li says he can feel their comfort level rise; even though he speaks what he calls “5-year-old Cantonese.”

“There is an improved therapeutic relationship when doctors and patients share a language, culture, or belief,” Dr. Li says. “There’s a level of comfort that you are going to be understood and nothing will be lost in translation.”

A patient’s culture may drive decisions contradictory to traditional Western medicine, and hospitalists need to make the time to listen and respond. Recently, Dr. Grewal treated a dying, elderly Asian patient whose family insisted on administering an unknown, water-like fluid to cure the loved one. First, the family requested giving the fluid to the patient by mouth. Dr. Grewal denied the request, and told them the water would end up in the patient’s lungs because he was comatose and could not swallow. Then, the family asked if they could add it to the intravenous line. Again, Dr. Grewal denied the request, and told them water in an un-buffered solution could be harmful to red blood cells.

“It was frustrating for them,” Dr. Grewal says. “I told them, ‘It’s not that I don’t believe the water will cure him. Maybe it will or maybe it won’t. But from a medical standpoint, I know there will be complications and I just cannot do this.’ ”

Eventually, the family asked if a tube could be inserted into the patient’s stomach. When the request was denied, the family decided on comfort care for their loved one. Eventually, he passed away. The family, Dr. Grewal says, was grateful for the hospital staff’s care and effort, even though their requests to administer the fluid were denied.

Difficult Cases

Firm cultural beliefs may lead patients to resist treatment. Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in New Brunswick, N.J., recalls working with an elderly member of the Indian community who refused to be transferred to a rehabilitation facility. Dr. Patel took time to speak to the patient and learned she came from a tradition that encouraged younger generations to care for the elderly. The patient interpreted her transfer to a rehabilitation facility as a sign her family was abandoning her, Dr. Patel says.

“Sometimes you have to probe to learn more,” Dr. Patel says. “Once we understood her fears, we were able to convey to her that this was a temporary situation and that her family could not provide her with the services that she needed at that point in time.”

Dr. Patel also interacts with Hispanic and Indian patients—many of whom revere doctors and defer to them for treatment decisions. In these situations, he uses the same approach as he does with patients who question his treatment recommendations.

“The patient may defer to you, but it’s important to empower the patient and give them all the information they need to make major choices in their healthcare.”

Information Pipeline

Hospitalists may prefer to be upfront about a patient’s condition and treatment, however, cultural norms sometimes dictate who receives information—and how much. For example, Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif., says some Asian families prefer medical staff deliver bad news about the patient to them first. The family then decides what they will tell the patient, he says.

These situations create challenges and opportunities, Enderby says. Medical staff tries to establish a patient-centric care system, so it is important to continue appropriate communication with the patient. It also is important for healthcare providers to avoid putting the family in the middle and marginalizing the patient, he says. Healthcare teams can become frustrated when family members are at odds about decisions and options, and the patient is not involved at the family’s request, he says. In these cases, Dr. Enderby sees an opportunity to further engage the family, and, therefore, the patient.

“Often, when there are cultural and language barriers, a disengaged family can make caring for the patient very challenging,” Dr. Enderby says. “Having the family involved can help everyone feel more aligned with a treatment plan or strategy.”

For Alpesh Amin, MD, associate professor of medicine and vice chair for Clinical Affairs and Quality in the Department of Medicine at the University of California Irvine School of Medicine, being aware of a patient’s cultural values is critical to quality care. As executive director of the hospitalist program at the UCI Medical Center in Orange, Calif., Dr. Amin helped develop curriculum to train students on how to collect “values history” from patients, which includes asking questions about religion and culture. Students document their own values history, and then ask the same questions of a patient. Students discuss patient care and the importance of these histories during small group sessions.

“Knowing a patient's cultural information is just as important as knowing their sexual history or drug history,” Dr. Amin says. “It’s another piece of information that helps you get to know them as a whole. Their overall care is more comprehensive, if you have this knowledge.” TH

Gina Gotsill is a journalist based in California.

Sharnjit Grewal, MD, a hospitalist at Mercy Medical Group in Sacramento, Calif., is familiar with what he calls “the double-take.” A Sikh born and raised in California, Dr. Grewal wears a traditional turban and full beard. When he walks into the room, some patient’s simply don’t know what to make of him, he admits.

“It’s confusing—even to my Hindu and Sikh patients,” Dr. Grewal says. “They sometimes say, ‘You talk like an American, you’re obviously from the West, but you follow a faith from the East. The line between religion and culture is obscured.”

Although the medical community stresses cultural awareness and sensitivity, Dr. Grewal’s experience highlights the fine line between religion and culture, and the barriers standing stand in the way of cultural awareness.

Today, hospitals experience shifting patient demographics and a growing number of languages and dialects observed in the United States today. Between 1990-2000, the foreign-born population in the U.S. increased by 57%, compared with a 9.3% increase for the native population and a 13% increase for the total U.S. population, according to the U.S. Census Bureau.

Break Down Walls

When hospitalists and patients share a culture or language, the result can be extremely positive. In fact, the Joint Commission report states some hospitals in the United States are working to increase racial and ethnic similarities between staff and patient populations.

Joseph Li, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston, frequently works with Cantonese-speaking patients referred to the hospital by the healthcare clinic in Boston’s Chinatown section. When he greets patients in their native tongue, Dr. Li says he can feel their comfort level rise; even though he speaks what he calls “5-year-old Cantonese.”

“There is an improved therapeutic relationship when doctors and patients share a language, culture, or belief,” Dr. Li says. “There’s a level of comfort that you are going to be understood and nothing will be lost in translation.”

A patient’s culture may drive decisions contradictory to traditional Western medicine, and hospitalists need to make the time to listen and respond. Recently, Dr. Grewal treated a dying, elderly Asian patient whose family insisted on administering an unknown, water-like fluid to cure the loved one. First, the family requested giving the fluid to the patient by mouth. Dr. Grewal denied the request, and told them the water would end up in the patient’s lungs because he was comatose and could not swallow. Then, the family asked if they could add it to the intravenous line. Again, Dr. Grewal denied the request, and told them water in an un-buffered solution could be harmful to red blood cells.

“It was frustrating for them,” Dr. Grewal says. “I told them, ‘It’s not that I don’t believe the water will cure him. Maybe it will or maybe it won’t. But from a medical standpoint, I know there will be complications and I just cannot do this.’ ”

Eventually, the family asked if a tube could be inserted into the patient’s stomach. When the request was denied, the family decided on comfort care for their loved one. Eventually, he passed away. The family, Dr. Grewal says, was grateful for the hospital staff’s care and effort, even though their requests to administer the fluid were denied.

Difficult Cases

Firm cultural beliefs may lead patients to resist treatment. Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in New Brunswick, N.J., recalls working with an elderly member of the Indian community who refused to be transferred to a rehabilitation facility. Dr. Patel took time to speak to the patient and learned she came from a tradition that encouraged younger generations to care for the elderly. The patient interpreted her transfer to a rehabilitation facility as a sign her family was abandoning her, Dr. Patel says.

“Sometimes you have to probe to learn more,” Dr. Patel says. “Once we understood her fears, we were able to convey to her that this was a temporary situation and that her family could not provide her with the services that she needed at that point in time.”

Dr. Patel also interacts with Hispanic and Indian patients—many of whom revere doctors and defer to them for treatment decisions. In these situations, he uses the same approach as he does with patients who question his treatment recommendations.

“The patient may defer to you, but it’s important to empower the patient and give them all the information they need to make major choices in their healthcare.”

Information Pipeline

Hospitalists may prefer to be upfront about a patient’s condition and treatment, however, cultural norms sometimes dictate who receives information—and how much. For example, Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif., says some Asian families prefer medical staff deliver bad news about the patient to them first. The family then decides what they will tell the patient, he says.

These situations create challenges and opportunities, Enderby says. Medical staff tries to establish a patient-centric care system, so it is important to continue appropriate communication with the patient. It also is important for healthcare providers to avoid putting the family in the middle and marginalizing the patient, he says. Healthcare teams can become frustrated when family members are at odds about decisions and options, and the patient is not involved at the family’s request, he says. In these cases, Dr. Enderby sees an opportunity to further engage the family, and, therefore, the patient.

“Often, when there are cultural and language barriers, a disengaged family can make caring for the patient very challenging,” Dr. Enderby says. “Having the family involved can help everyone feel more aligned with a treatment plan or strategy.”

For Alpesh Amin, MD, associate professor of medicine and vice chair for Clinical Affairs and Quality in the Department of Medicine at the University of California Irvine School of Medicine, being aware of a patient’s cultural values is critical to quality care. As executive director of the hospitalist program at the UCI Medical Center in Orange, Calif., Dr. Amin helped develop curriculum to train students on how to collect “values history” from patients, which includes asking questions about religion and culture. Students document their own values history, and then ask the same questions of a patient. Students discuss patient care and the importance of these histories during small group sessions.

“Knowing a patient's cultural information is just as important as knowing their sexual history or drug history,” Dr. Amin says. “It’s another piece of information that helps you get to know them as a whole. Their overall care is more comprehensive, if you have this knowledge.” TH

Gina Gotsill is a journalist based in California.

Several years ago, a patient at Virtua West Jersey Hospital Marlton, in Marlton, N.J., was diagnosed with metastatic colon cancer with spinal metastases. The patient was septic, bleeding from a spinal wound, and was experiencing kidney failure. Hospitalists recommended stopping treatment and moving the patient to hospice care. The patient’s family refused, and told hospitalists that, according to their Christian faith, suffering was the only true path to heaven. Hospitalists kept the patient as comfortable as possible, but blood pressure problems and hypotension made it difficult for them to administer pain medication.

Hospitalists held numerous meetings with the family and medical and nursing staff to discuss the ethical implications of the situation. Two months later, the patient suffered cardiac arrest and died.

“The medical staff and family were continuously at odds because the patient was suffering so much,” says Marianne Holler, DO, a hospitalist at University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, who was part of the patient’s medical team. “We were never able to discontinue life support throughout [the patient’s] hospital stay.”

Whether planning a routine procedure or end-of-life care, hospitalists may be called into religious discussions with patients, their families, spiritual advisors, and hospital chaplains. While many hospitalists have received ethics and other professional training to prepare them for these conversations, some say the intersection of religion and medicine remains a challenging and multifaceted aspect of their practice.

A Hospitalist’s Belief

Hospitalists’ brief relationships with patients may influence the degree of knowledge they have about an individual’s religious beliefs, says Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif. Over the years, primary care physicians may become less involved with a patient’s acute medical needs as they use hospitalist services to manage their inpatients, Dr. Enderby says. This means hospitalists must discuss patients’ wishes regarding code status and resuscitation, end-of-life care, and other necessary treatments.

When discussing religion and treatment, hospitalists must put aside their personal beliefs, and this may not always be easy, says Dr. Thomas McIlraith, MD, medical director of Hospital Medicine at Mercy Medical Group in Sacramento, Calif. Dr. McIlraith recalls a Jehovah’s Witness patient who cited religious beliefs when refusing a blood transfusion following a massive post-partum hemorrhage. The patient was severely anemic, and her hemoglobin levels plunged dangerously to 2 gm/dL. Leaders from the patient’s church asked Dr. McIlraith to try hemoglobin substitutes, but he was unable to do so because these substitutes still were experimental and associated with significant complications, he says.

Dr. McIlraith had to act fast. He instructed the obstetrician on the case to stop drawing hemoglobin levels; the patient needed every drop of blood she had to carry oxygen. He administered erythropoietin and iron to stimulate red blood cell production. He also put the patient on high flow oxygen to help saturate the plasma. The patient survived without a blood transfusion or significant complications.

“I didn’t think [the patient] was going to make it,” says Dr. McIlraith. “This was a very difficult situation because I knew they would have benefited from a blood transfusion. But, I presented them with their options and respected their wishes.”

Religious Diversity

Religious diversity can be another challenging aspect of patient care. In its 2008 U.S. Religious Landscapes Survey, the Pew Forum on Religion and Public Life interviewed 35,000 Americans age 18 and older and found “religious affiliation in the U.S. is both very diverse and extremely fluid.” The survey also found “people who are unaffiliated with any particular religion (16.1%) also exhibit remarkable internal diversity.”

Asking questions is the key to understanding a patient’s religious and spiritual needs, says the Rev. Peter Yuichi Clark, PhD, chaplain administrator at Alta Bates Summit Medical Center in Berkeley, Calif., who works closely with medical teams to assess and respond to these needs.

“I don’t assume I know what a patient’s religious needs are—even if I know what religion they profess to be,” Clark says. “Some patients may be very devout but do not practice certain aspects of their religion, while others follow a religion in name only but look for religious support during a time of crisis.”

Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, says it is impossible to predict an individual’s religious beliefs and how that may affect their hospital stay—even when the physician practices the same religion as the patient. For example, Dr. Patel knows that some, but not all, Hindus observe a strict vegetarian diet and that Vitamin B12 deficiencies are more prevalent in vegetarian populations. However, diet may not be the cause of this deficiency if the patient is not a vegetarian. Rather than assume, it’s important to ask Hindu patients if they observe a vegetarian diet, Dr. Patel says.

Some hospitalists find it difficult to engage patients in conversations about religion. In a study published in the June 2007 edition of the Journal of Palliative Medicine, researchers found physicians’ knowledge of factors relating to end-of-life care, which included patients’ religious and spiritual concerns and whether they affect decisions regarding end-of-life care, is poor.1

Hospitalists don’t have much time to get to know the person, so it’s even more important for them to have conversations about religion and end-of-life-care, says the study’s lead author Susan DesHarnais, PhD, of Pennsylvania State University’s Hershey Department of Public Health Sciences, Milton S. Hershey Medical Center College of Medicine. As important as these conversations are, Dr. DesHarnais learned hospitalists rarely have them.

When asked why she thinks these conversations rarely occur, Dr. DesHarnais said the research did not directly address that question, but she suspects the physicians don’t have a lot of time. Also, end-of-life decision-making is difficult, and some people are not comfortable talking about it, she says.

“Another factor may be that hospitalists are used to using technology for medical intervention more than they are used to working with people when not much more can be done,” she says.

Dr. Holler, who worked as a social worker before attending medical school, agrees that many physicians are uncomfortable with end-of-life decisions.

“Many physicians are 25 to 30 years old during their training,” says Dr. Holler. “They have been in school for many years. Some are discovering their own spiritual identity at the same time they are dealing, or learning to deal, with patients and families and where they are spiritually or religiously. Many haven’t dealt with these issues in their own personal lives yet.”

While Dr. Holler says she believes most doctors are caring and compassionate, end-of-life and religious discussions use different skill sets than those that preserve and extend life. “Often times we are not taught when enough is enough and how to convey that to patients and families,” says Dr. Holler. “Many doctors are afraid that they are conveying that they are giving up or that it isn’t worth it in the long run. So, many physicians find it easier to ‘keep going.’ ”

The Medical Community’s Response

The medical community is responding to shifting cultural and religious demographics, and more doctors are paying attention to religious diversity, Clark says. But a 2003 Joint Commision study of 60 public and private hospitals across the country, “Hospitals, Language and Culture: A Snapshot of the Nation,” found that hospitals still have work to do in this area.

“We found that hospitals are collecting data on patients’ religion, but it’s just not clear how they use it to improve services,” says Amy Wilson-Stronks, project director for health disparities with the Joint Commission and principal investigator of the study.

The current Joint Commission standards require hospitals to respect patients’ spiritual needs, beliefs, and values. Spiritual care issues first appeared in the 1969 accreditation manual and were adopted into standards in 1992, Wilson-Stronks says.

Accomodating Patients

Awareness and communication can benefit patients, hospitalists, and medical staff as a whole. For example, Alta Bates Summit’s intensive care unit staff in Berkely, Calif., turned to Chaplaincy Services about Muslim patients’ requests to continue their daily prayers, which include thorough washing of their hands, forearms, and other parts of their bodies (even when intravenous lines are attached). Chaplaincy Services reached out to an Islamic network group for advice and learned patients could rub a stone across their bodies to wash themselves. Chaplaincy Services now makes these stones available for staff and patients, Clark says.

Medical staff also works with Chaplaincy Services to accommodate Muslim patients’ wishes to face in the direction of Mecca during prayer, which can require maneuvering beds and other equipment, he says.

Some patients and their families may not understand how their religious tradition addresses code status, resuscitation, and when it is appropriate to withhold treatment, says Richard Rohr, MD, vice president of medical affairs at Cortland Regional Medical Center in Cortland, N.Y. While working as a hospitalist, Dr. Rohr suggested moving a terminal patient to palliative care and seeking a do not resuscitate (DNR) order. The patient’s family refused, and told Dr. Rohr they were Catholic and a DNR would violate their religious beliefs.

According to Dr. Rohr, DNR status and palliative care are described in the code of ethics adopted by the Catholic Health Association, and this type of care is generally provided at Catholic hospitals.

“I gently told them that this was within their religion, but they said no to palliative care and the DNR,” Dr. Rohr says. “The patient eventually died but it was much more difficult for them. They were subjected to active treatment that they couldn’t really benefit from.”

Families often seek the advice of spiritual advisors when making difficult decisions about code status and DNR orders. Barbara Egan, MD, a hospitalist at Memorial Sloan-Kettering Cancer Center in New York City, recalls treating an Orthodox Jewish patient who was suffering from end-stage disease. Death was imminent, and hospitalists recommended palliative care. The patient’s family members balked at the recommendation and insisted hospitalists “do everything possible” to treat their loved one. Soon after, the family’s rabbi arrived to counsel the family. After visiting the patient and speaking to medical staff about the prognosis, the rabbi urged the family not to pursue further treatment or artificial resuscitation. The patient was moved to a palliative care unit and passed away within a few days.

“The family’s rabbi told them exactly what I had: that there were no useful medical interventions for the patient,” Dr. Egan says. “But they really needed to hear it from him before they could come to an agreement on a DNR.”

Physicians’ reactions to religion at the bedside have evolved the past 25 years, says Kenneth Patrick, MD, ICU director at Chestnut Hill Hospital in Philadelphia. Physicians were more paternalistic then, and believed they knew what was best for their patients—and their families—regardless of their patient’s religious beliefs.

While serving as a fellow at Memorial Sloan-Kettering Cancer Center, Dr. Patrick worked with a terminally ill Buddhist patient in the intensive care unit. When death was imminent, the ICU director allowed Buddhist monks to light candles and pray in the room during the hours leading up to the patient’s death. At the time, this was not something that was normally done in a hospital, Dr. Patrick says. While the ritual may have kept medical staff from checking vital signs as often as they would have normally, he says this did not affect the patient’s treatment.

“I believe it is incumbent on the hospitalist to adjust his or her beliefs to be more accepting of our patients’ values,” Dr. Patrick says. “I can agree to any request I find to be reasonable and in the patient’s best interest, even if it is different than what I believe.” TH

Gina Gotsill is a journalist based in California.

Reference

1. DesHarnais S, Carter RE, Hennessy W, Kurent JE, Carter C. Lack of concordance between physicians and patient: Reports on end-of-life care discussions. J Pall Med. 2007 June;10(3):728-740.

Several years ago, a patient at Virtua West Jersey Hospital Marlton, in Marlton, N.J., was diagnosed with metastatic colon cancer with spinal metastases. The patient was septic, bleeding from a spinal wound, and was experiencing kidney failure. Hospitalists recommended stopping treatment and moving the patient to hospice care. The patient’s family refused, and told hospitalists that, according to their Christian faith, suffering was the only true path to heaven. Hospitalists kept the patient as comfortable as possible, but blood pressure problems and hypotension made it difficult for them to administer pain medication.

Hospitalists held numerous meetings with the family and medical and nursing staff to discuss the ethical implications of the situation. Two months later, the patient suffered cardiac arrest and died.

“The medical staff and family were continuously at odds because the patient was suffering so much,” says Marianne Holler, DO, a hospitalist at University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, who was part of the patient’s medical team. “We were never able to discontinue life support throughout [the patient’s] hospital stay.”

Whether planning a routine procedure or end-of-life care, hospitalists may be called into religious discussions with patients, their families, spiritual advisors, and hospital chaplains. While many hospitalists have received ethics and other professional training to prepare them for these conversations, some say the intersection of religion and medicine remains a challenging and multifaceted aspect of their practice.

A Hospitalist’s Belief

Hospitalists’ brief relationships with patients may influence the degree of knowledge they have about an individual’s religious beliefs, says Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif. Over the years, primary care physicians may become less involved with a patient’s acute medical needs as they use hospitalist services to manage their inpatients, Dr. Enderby says. This means hospitalists must discuss patients’ wishes regarding code status and resuscitation, end-of-life care, and other necessary treatments.

When discussing religion and treatment, hospitalists must put aside their personal beliefs, and this may not always be easy, says Dr. Thomas McIlraith, MD, medical director of Hospital Medicine at Mercy Medical Group in Sacramento, Calif. Dr. McIlraith recalls a Jehovah’s Witness patient who cited religious beliefs when refusing a blood transfusion following a massive post-partum hemorrhage. The patient was severely anemic, and her hemoglobin levels plunged dangerously to 2 gm/dL. Leaders from the patient’s church asked Dr. McIlraith to try hemoglobin substitutes, but he was unable to do so because these substitutes still were experimental and associated with significant complications, he says.

Dr. McIlraith had to act fast. He instructed the obstetrician on the case to stop drawing hemoglobin levels; the patient needed every drop of blood she had to carry oxygen. He administered erythropoietin and iron to stimulate red blood cell production. He also put the patient on high flow oxygen to help saturate the plasma. The patient survived without a blood transfusion or significant complications.

“I didn’t think [the patient] was going to make it,” says Dr. McIlraith. “This was a very difficult situation because I knew they would have benefited from a blood transfusion. But, I presented them with their options and respected their wishes.”

Religious Diversity

Religious diversity can be another challenging aspect of patient care. In its 2008 U.S. Religious Landscapes Survey, the Pew Forum on Religion and Public Life interviewed 35,000 Americans age 18 and older and found “religious affiliation in the U.S. is both very diverse and extremely fluid.” The survey also found “people who are unaffiliated with any particular religion (16.1%) also exhibit remarkable internal diversity.”

Asking questions is the key to understanding a patient’s religious and spiritual needs, says the Rev. Peter Yuichi Clark, PhD, chaplain administrator at Alta Bates Summit Medical Center in Berkeley, Calif., who works closely with medical teams to assess and respond to these needs.

“I don’t assume I know what a patient’s religious needs are—even if I know what religion they profess to be,” Clark says. “Some patients may be very devout but do not practice certain aspects of their religion, while others follow a religion in name only but look for religious support during a time of crisis.”

Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, says it is impossible to predict an individual’s religious beliefs and how that may affect their hospital stay—even when the physician practices the same religion as the patient. For example, Dr. Patel knows that some, but not all, Hindus observe a strict vegetarian diet and that Vitamin B12 deficiencies are more prevalent in vegetarian populations. However, diet may not be the cause of this deficiency if the patient is not a vegetarian. Rather than assume, it’s important to ask Hindu patients if they observe a vegetarian diet, Dr. Patel says.

Some hospitalists find it difficult to engage patients in conversations about religion. In a study published in the June 2007 edition of the Journal of Palliative Medicine, researchers found physicians’ knowledge of factors relating to end-of-life care, which included patients’ religious and spiritual concerns and whether they affect decisions regarding end-of-life care, is poor.1

Hospitalists don’t have much time to get to know the person, so it’s even more important for them to have conversations about religion and end-of-life-care, says the study’s lead author Susan DesHarnais, PhD, of Pennsylvania State University’s Hershey Department of Public Health Sciences, Milton S. Hershey Medical Center College of Medicine. As important as these conversations are, Dr. DesHarnais learned hospitalists rarely have them.

When asked why she thinks these conversations rarely occur, Dr. DesHarnais said the research did not directly address that question, but she suspects the physicians don’t have a lot of time. Also, end-of-life decision-making is difficult, and some people are not comfortable talking about it, she says.

“Another factor may be that hospitalists are used to using technology for medical intervention more than they are used to working with people when not much more can be done,” she says.

Dr. Holler, who worked as a social worker before attending medical school, agrees that many physicians are uncomfortable with end-of-life decisions.

“Many physicians are 25 to 30 years old during their training,” says Dr. Holler. “They have been in school for many years. Some are discovering their own spiritual identity at the same time they are dealing, or learning to deal, with patients and families and where they are spiritually or religiously. Many haven’t dealt with these issues in their own personal lives yet.”

While Dr. Holler says she believes most doctors are caring and compassionate, end-of-life and religious discussions use different skill sets than those that preserve and extend life. “Often times we are not taught when enough is enough and how to convey that to patients and families,” says Dr. Holler. “Many doctors are afraid that they are conveying that they are giving up or that it isn’t worth it in the long run. So, many physicians find it easier to ‘keep going.’ ”

The Medical Community’s Response

The medical community is responding to shifting cultural and religious demographics, and more doctors are paying attention to religious diversity, Clark says. But a 2003 Joint Commision study of 60 public and private hospitals across the country, “Hospitals, Language and Culture: A Snapshot of the Nation,” found that hospitals still have work to do in this area.

“We found that hospitals are collecting data on patients’ religion, but it’s just not clear how they use it to improve services,” says Amy Wilson-Stronks, project director for health disparities with the Joint Commission and principal investigator of the study.

The current Joint Commission standards require hospitals to respect patients’ spiritual needs, beliefs, and values. Spiritual care issues first appeared in the 1969 accreditation manual and were adopted into standards in 1992, Wilson-Stronks says.

Accomodating Patients

Awareness and communication can benefit patients, hospitalists, and medical staff as a whole. For example, Alta Bates Summit’s intensive care unit staff in Berkely, Calif., turned to Chaplaincy Services about Muslim patients’ requests to continue their daily prayers, which include thorough washing of their hands, forearms, and other parts of their bodies (even when intravenous lines are attached). Chaplaincy Services reached out to an Islamic network group for advice and learned patients could rub a stone across their bodies to wash themselves. Chaplaincy Services now makes these stones available for staff and patients, Clark says.

Medical staff also works with Chaplaincy Services to accommodate Muslim patients’ wishes to face in the direction of Mecca during prayer, which can require maneuvering beds and other equipment, he says.

Some patients and their families may not understand how their religious tradition addresses code status, resuscitation, and when it is appropriate to withhold treatment, says Richard Rohr, MD, vice president of medical affairs at Cortland Regional Medical Center in Cortland, N.Y. While working as a hospitalist, Dr. Rohr suggested moving a terminal patient to palliative care and seeking a do not resuscitate (DNR) order. The patient’s family refused, and told Dr. Rohr they were Catholic and a DNR would violate their religious beliefs.

According to Dr. Rohr, DNR status and palliative care are described in the code of ethics adopted by the Catholic Health Association, and this type of care is generally provided at Catholic hospitals.

“I gently told them that this was within their religion, but they said no to palliative care and the DNR,” Dr. Rohr says. “The patient eventually died but it was much more difficult for them. They were subjected to active treatment that they couldn’t really benefit from.”

Families often seek the advice of spiritual advisors when making difficult decisions about code status and DNR orders. Barbara Egan, MD, a hospitalist at Memorial Sloan-Kettering Cancer Center in New York City, recalls treating an Orthodox Jewish patient who was suffering from end-stage disease. Death was imminent, and hospitalists recommended palliative care. The patient’s family members balked at the recommendation and insisted hospitalists “do everything possible” to treat their loved one. Soon after, the family’s rabbi arrived to counsel the family. After visiting the patient and speaking to medical staff about the prognosis, the rabbi urged the family not to pursue further treatment or artificial resuscitation. The patient was moved to a palliative care unit and passed away within a few days.

“The family’s rabbi told them exactly what I had: that there were no useful medical interventions for the patient,” Dr. Egan says. “But they really needed to hear it from him before they could come to an agreement on a DNR.”

Physicians’ reactions to religion at the bedside have evolved the past 25 years, says Kenneth Patrick, MD, ICU director at Chestnut Hill Hospital in Philadelphia. Physicians were more paternalistic then, and believed they knew what was best for their patients—and their families—regardless of their patient’s religious beliefs.

While serving as a fellow at Memorial Sloan-Kettering Cancer Center, Dr. Patrick worked with a terminally ill Buddhist patient in the intensive care unit. When death was imminent, the ICU director allowed Buddhist monks to light candles and pray in the room during the hours leading up to the patient’s death. At the time, this was not something that was normally done in a hospital, Dr. Patrick says. While the ritual may have kept medical staff from checking vital signs as often as they would have normally, he says this did not affect the patient’s treatment.

“I believe it is incumbent on the hospitalist to adjust his or her beliefs to be more accepting of our patients’ values,” Dr. Patrick says. “I can agree to any request I find to be reasonable and in the patient’s best interest, even if it is different than what I believe.” TH

Gina Gotsill is a journalist based in California.

Reference

1. DesHarnais S, Carter RE, Hennessy W, Kurent JE, Carter C. Lack of concordance between physicians and patient: Reports on end-of-life care discussions. J Pall Med. 2007 June;10(3):728-740.

Several years ago, a patient at Virtua West Jersey Hospital Marlton, in Marlton, N.J., was diagnosed with metastatic colon cancer with spinal metastases. The patient was septic, bleeding from a spinal wound, and was experiencing kidney failure. Hospitalists recommended stopping treatment and moving the patient to hospice care. The patient’s family refused, and told hospitalists that, according to their Christian faith, suffering was the only true path to heaven. Hospitalists kept the patient as comfortable as possible, but blood pressure problems and hypotension made it difficult for them to administer pain medication.

Hospitalists held numerous meetings with the family and medical and nursing staff to discuss the ethical implications of the situation. Two months later, the patient suffered cardiac arrest and died.

“The medical staff and family were continuously at odds because the patient was suffering so much,” says Marianne Holler, DO, a hospitalist at University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, who was part of the patient’s medical team. “We were never able to discontinue life support throughout [the patient’s] hospital stay.”

Whether planning a routine procedure or end-of-life care, hospitalists may be called into religious discussions with patients, their families, spiritual advisors, and hospital chaplains. While many hospitalists have received ethics and other professional training to prepare them for these conversations, some say the intersection of religion and medicine remains a challenging and multifaceted aspect of their practice.

A Hospitalist’s Belief

Hospitalists’ brief relationships with patients may influence the degree of knowledge they have about an individual’s religious beliefs, says Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif. Over the years, primary care physicians may become less involved with a patient’s acute medical needs as they use hospitalist services to manage their inpatients, Dr. Enderby says. This means hospitalists must discuss patients’ wishes regarding code status and resuscitation, end-of-life care, and other necessary treatments.

When discussing religion and treatment, hospitalists must put aside their personal beliefs, and this may not always be easy, says Dr. Thomas McIlraith, MD, medical director of Hospital Medicine at Mercy Medical Group in Sacramento, Calif. Dr. McIlraith recalls a Jehovah’s Witness patient who cited religious beliefs when refusing a blood transfusion following a massive post-partum hemorrhage. The patient was severely anemic, and her hemoglobin levels plunged dangerously to 2 gm/dL. Leaders from the patient’s church asked Dr. McIlraith to try hemoglobin substitutes, but he was unable to do so because these substitutes still were experimental and associated with significant complications, he says.

Dr. McIlraith had to act fast. He instructed the obstetrician on the case to stop drawing hemoglobin levels; the patient needed every drop of blood she had to carry oxygen. He administered erythropoietin and iron to stimulate red blood cell production. He also put the patient on high flow oxygen to help saturate the plasma. The patient survived without a blood transfusion or significant complications.

“I didn’t think [the patient] was going to make it,” says Dr. McIlraith. “This was a very difficult situation because I knew they would have benefited from a blood transfusion. But, I presented them with their options and respected their wishes.”

Religious Diversity

Religious diversity can be another challenging aspect of patient care. In its 2008 U.S. Religious Landscapes Survey, the Pew Forum on Religion and Public Life interviewed 35,000 Americans age 18 and older and found “religious affiliation in the U.S. is both very diverse and extremely fluid.” The survey also found “people who are unaffiliated with any particular religion (16.1%) also exhibit remarkable internal diversity.”

Asking questions is the key to understanding a patient’s religious and spiritual needs, says the Rev. Peter Yuichi Clark, PhD, chaplain administrator at Alta Bates Summit Medical Center in Berkeley, Calif., who works closely with medical teams to assess and respond to these needs.

“I don’t assume I know what a patient’s religious needs are—even if I know what religion they profess to be,” Clark says. “Some patients may be very devout but do not practice certain aspects of their religion, while others follow a religion in name only but look for religious support during a time of crisis.”

Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, says it is impossible to predict an individual’s religious beliefs and how that may affect their hospital stay—even when the physician practices the same religion as the patient. For example, Dr. Patel knows that some, but not all, Hindus observe a strict vegetarian diet and that Vitamin B12 deficiencies are more prevalent in vegetarian populations. However, diet may not be the cause of this deficiency if the patient is not a vegetarian. Rather than assume, it’s important to ask Hindu patients if they observe a vegetarian diet, Dr. Patel says.

Some hospitalists find it difficult to engage patients in conversations about religion. In a study published in the June 2007 edition of the Journal of Palliative Medicine, researchers found physicians’ knowledge of factors relating to end-of-life care, which included patients’ religious and spiritual concerns and whether they affect decisions regarding end-of-life care, is poor.1

Hospitalists don’t have much time to get to know the person, so it’s even more important for them to have conversations about religion and end-of-life-care, says the study’s lead author Susan DesHarnais, PhD, of Pennsylvania State University’s Hershey Department of Public Health Sciences, Milton S. Hershey Medical Center College of Medicine. As important as these conversations are, Dr. DesHarnais learned hospitalists rarely have them.

When asked why she thinks these conversations rarely occur, Dr. DesHarnais said the research did not directly address that question, but she suspects the physicians don’t have a lot of time. Also, end-of-life decision-making is difficult, and some people are not comfortable talking about it, she says.

“Another factor may be that hospitalists are used to using technology for medical intervention more than they are used to working with people when not much more can be done,” she says.

Dr. Holler, who worked as a social worker before attending medical school, agrees that many physicians are uncomfortable with end-of-life decisions.

“Many physicians are 25 to 30 years old during their training,” says Dr. Holler. “They have been in school for many years. Some are discovering their own spiritual identity at the same time they are dealing, or learning to deal, with patients and families and where they are spiritually or religiously. Many haven’t dealt with these issues in their own personal lives yet.”

While Dr. Holler says she believes most doctors are caring and compassionate, end-of-life and religious discussions use different skill sets than those that preserve and extend life. “Often times we are not taught when enough is enough and how to convey that to patients and families,” says Dr. Holler. “Many doctors are afraid that they are conveying that they are giving up or that it isn’t worth it in the long run. So, many physicians find it easier to ‘keep going.’ ”

The Medical Community’s Response

The medical community is responding to shifting cultural and religious demographics, and more doctors are paying attention to religious diversity, Clark says. But a 2003 Joint Commision study of 60 public and private hospitals across the country, “Hospitals, Language and Culture: A Snapshot of the Nation,” found that hospitals still have work to do in this area.

“We found that hospitals are collecting data on patients’ religion, but it’s just not clear how they use it to improve services,” says Amy Wilson-Stronks, project director for health disparities with the Joint Commission and principal investigator of the study.

The current Joint Commission standards require hospitals to respect patients’ spiritual needs, beliefs, and values. Spiritual care issues first appeared in the 1969 accreditation manual and were adopted into standards in 1992, Wilson-Stronks says.

Accomodating Patients

Awareness and communication can benefit patients, hospitalists, and medical staff as a whole. For example, Alta Bates Summit’s intensive care unit staff in Berkely, Calif., turned to Chaplaincy Services about Muslim patients’ requests to continue their daily prayers, which include thorough washing of their hands, forearms, and other parts of their bodies (even when intravenous lines are attached). Chaplaincy Services reached out to an Islamic network group for advice and learned patients could rub a stone across their bodies to wash themselves. Chaplaincy Services now makes these stones available for staff and patients, Clark says.

Medical staff also works with Chaplaincy Services to accommodate Muslim patients’ wishes to face in the direction of Mecca during prayer, which can require maneuvering beds and other equipment, he says.

Some patients and their families may not understand how their religious tradition addresses code status, resuscitation, and when it is appropriate to withhold treatment, says Richard Rohr, MD, vice president of medical affairs at Cortland Regional Medical Center in Cortland, N.Y. While working as a hospitalist, Dr. Rohr suggested moving a terminal patient to palliative care and seeking a do not resuscitate (DNR) order. The patient’s family refused, and told Dr. Rohr they were Catholic and a DNR would violate their religious beliefs.

According to Dr. Rohr, DNR status and palliative care are described in the code of ethics adopted by the Catholic Health Association, and this type of care is generally provided at Catholic hospitals.

“I gently told them that this was within their religion, but they said no to palliative care and the DNR,” Dr. Rohr says. “The patient eventually died but it was much more difficult for them. They were subjected to active treatment that they couldn’t really benefit from.”

Families often seek the advice of spiritual advisors when making difficult decisions about code status and DNR orders. Barbara Egan, MD, a hospitalist at Memorial Sloan-Kettering Cancer Center in New York City, recalls treating an Orthodox Jewish patient who was suffering from end-stage disease. Death was imminent, and hospitalists recommended palliative care. The patient’s family members balked at the recommendation and insisted hospitalists “do everything possible” to treat their loved one. Soon after, the family’s rabbi arrived to counsel the family. After visiting the patient and speaking to medical staff about the prognosis, the rabbi urged the family not to pursue further treatment or artificial resuscitation. The patient was moved to a palliative care unit and passed away within a few days.

“The family’s rabbi told them exactly what I had: that there were no useful medical interventions for the patient,” Dr. Egan says. “But they really needed to hear it from him before they could come to an agreement on a DNR.”

Physicians’ reactions to religion at the bedside have evolved the past 25 years, says Kenneth Patrick, MD, ICU director at Chestnut Hill Hospital in Philadelphia. Physicians were more paternalistic then, and believed they knew what was best for their patients—and their families—regardless of their patient’s religious beliefs.

While serving as a fellow at Memorial Sloan-Kettering Cancer Center, Dr. Patrick worked with a terminally ill Buddhist patient in the intensive care unit. When death was imminent, the ICU director allowed Buddhist monks to light candles and pray in the room during the hours leading up to the patient’s death. At the time, this was not something that was normally done in a hospital, Dr. Patrick says. While the ritual may have kept medical staff from checking vital signs as often as they would have normally, he says this did not affect the patient’s treatment.

“I believe it is incumbent on the hospitalist to adjust his or her beliefs to be more accepting of our patients’ values,” Dr. Patrick says. “I can agree to any request I find to be reasonable and in the patient’s best interest, even if it is different than what I believe.” TH

Gina Gotsill is a journalist based in California.

Reference

1. DesHarnais S, Carter RE, Hennessy W, Kurent JE, Carter C. Lack of concordance between physicians and patient: Reports on end-of-life care discussions. J Pall Med. 2007 June;10(3):728-740.