Larry Beresford

Note: This is Part 2 of The Hospitalist’s series on pain and hospital medicine. Part 1 appeared on p. 45 of the April issue.

Welcome to Part 2 of our three-part series on managing the pain of hospitalized patients. Last month’s article presented the context for pain management in the hospital—a core competency identified by SHM. It emphasized techniques for assessing patients’ pain, ranging from a zero-to-10 pain score to more complex pain histories addressing type, source, duration, and intensity as well as psychosocial and spiritual factors.

Part 2 delves into some difficult cases and dilemmas of pain management—situations that can take hospitalists out of their comfort zone and challenge their confidence in managing their patients’ pain.

Some of these dilemmas arise from misconceptions about pain and pain treatments and from the fact that, historically, physicians have not been well trained in optimal pain management. General barriers to pain management in the U.S. healthcare system, as identified by the National Association of Attorneys General, include patients’ beliefs, physician and institutional practices, restrictive state polices, and racial and socioeconomic disparities.1

Many of these issues relate specifically to the most common treatments for severe pain, opioid analgesics, which have all sorts of negative associations based on misconceptions about abuse, addiction, and overdose. In other cases, physicians face real challenges in balancing analgesic benefits with side effects and in determining the right medication, dose, and schedule to meet the patient’s need for pain relief.

Hospitalists confronting difficult pain cases work under the added pressure of trying to bring their patients’ acute illnesses under control so they can discharge them to a lower level of care as soon as prudently possible. This time pressure, along with demands arising from the rest of the hospitalist’s caseload, may impose limits on what can be accomplished in difficult situations or with medications that require time to stabilize.

Challenges also arise when the customary approach to pain management—the drug and dosing schedule the hospitalist is most comfortable using for most patients—fails to bring the pain under control. This is often a red flag for the need to try something new, says Stephen Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and a consultant on the medical center’s palliative care service. In some cases, that means calling in a specialist in pain treatment, palliative medicine, psychiatry, or substance abuse.

“You need to work into the equation that there are pitfalls and caveats to everything we say about pain,” Dr. Bekanich observes. “Plus, the common pain treatments are controlled substances, with obvious legal implications and a professional duty for physicians to handle them safely and appropriately.”

When Dr. Bekanich finds himself confronting a difficult pain situation that has caused a conflict with a patient, he often involves one of the hospital’s customer service patient advocates. They are trained to mediate disagreements between patients and the treatment team.

Is This Patient’s Pain Real?

Physicians sometimes wonder if their patients’ reports of pain are accurate. Is the pain really as bad as the patient says it is? “Residents, frequently, are more skeptical of patients’ claims of pain, doubting whether they are truly experiencing that level of pain,” reports Jean Youngwerth, MD, a hospitalist, palliative care consultant, and fellowship associate program director at the University of Colorado Health Sciences Center in Aurora.

“I tell my residents that malingering is rare, and those few cases where it happens really tend to stand out,” Dr. Young­werth says. “I also tell them that our default position is always to trust the patient, unless given a good reason not to. I have been burned more often when I questioned my patients’ reports of pain than when I didn’t.”

Pain experts emphasize that the patient’s self-report is the most reliable source of information on pain—based on an understanding of pain as a complex, subjective phenomenon associated with actual or potential tissue damage and the patient’s perception of and emotional reaction to that sensation. The phenomenon of pain also includes emotional, social, psychological, even spiritual components and can be mediated by a host of other factors. But that doesn’t mean it isn’t real to the patient.

“Often, younger physicians take the attitude that if the pain is real, then administration of morphine will make it go away,” says Porter Storey, MD, FACP, FAAHPM. “In reality, pain doesn’t always respond to opioids, for all sorts of reasons. Hospitalists value clarity, and they use pain as a screen for all sorts of other problems. Their goal, often, is not so much the comfort of the patient as it is diagnosing, treating, and then discharging the patient from the hospital.” Dr. Storey is a palliative care physician in Boulder, Colo., and executive vice president for Medical Affairs at the American Academy of Hospice and Palliative Medicine (AAHPM).

Physicians need to be reminded, however, that unresolved pain in hospitalized patients has many negative consequences. These range from resistance to rehabilitation to depression to delayed hospital discharge, as well as reduced job satisfaction for the healthcare professionals who care for them.

Will Prescribing Analgesics Cause Addiction?

Fears about causing addiction haunt many pain management discussions. Requests for more medications, obsessing over the next scheduled analgesic dose, and even manipulative or drug-seeking behaviors can be misunderstood by physicians who lack training in the real nature of drug addiction. Actual cases of drug addiction created by appropriate, sufficient, and well-monitored opioid analgesic treatment are rare, pain experts say. There is an important caveat: the patient who brings a prior history of drug abuse to the current acute medical episode.

“There are no good data about iatrogenic addiction,” says Robert Brody, MD, chief of the pain consultation clinic at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. “People who do pain management, certainly including hospice and palliative care physicians, don’t really believe in it. In my own clinical experience, most patients don’t like pain medications and stop them as soon as they can.”

Addiction is more accurately understood as the inappropriate use of a drug for non-medical purposes. It refers to disruptive, drug-seeking behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.2 Addiction experts also describe addiction as a disease syndrome in its own right. Although that concept can sometimes be hard to accept by those who don’t have a lot of experience working with it, it is a useful paradigm to treat addiction as if it were a disease, says Ronald Crossno, MD, Rockdale, Texas-based area medical director for the VistaCare hospice chain.

Pain experts use the term pseudoaddiction for behaviors that are reminiscent of addiction but in fact reflect the pursuit of pain relief. Examples might include hoarding drugs, clock-watching, and exaggerated complaints of pain, such as moaning or crying. If it is pseudoaddiction, once the pain is brought under control, these behaviors cease. The term was coined in 1989 to describe an iatrogenic syndrome resulting from poorly treated pain.3-5

“Pseudoaddiction is a term you need to know,” Dr. Crossno asserted during a presentation on addiction pain at the recent annual conference of AAHPM in Salt Lake City in February. “It is at least as prevalent as addiction—and an indictment of how our healthcare system deals with pain.”

Dr. Youngwerth offers some advice.“We often see pseudoaddiction in response to undertreatment and inadequately managed pain,” she says. “If you treat the pain appropriately, these behaviors go away.” She tries to teach this concept to residents and hospital staff, who sometimes find it hard to put themselves in the shoes of patients experiencing severe pain.

“If you have a 68-year-old patient with no history of addiction or substance abuse who is in the hospital [with the] status post-hip replacement and is now clock-watching and routinely pressing the call button before her next dose of opioids is due, staff may feel that she is displaying addictive behaviors,” Dr. Youngwerth says. “Why would they think that this situation evolved into addiction during her brief hospital stay? It’s more likely that she’s just afraid of having pain.”

The solution to pseudoaddiction is to prescribe opioids at pharmacologically appropriate doses and schedules. Then, titrate up until analgesia is achieved or toxicities necessitate alternative approaches. Use all the techniques described in the first article of this series. It is also important to restore trust and the patient’s confidence in the medical system’s ability to manage his or her pain. Opioid pain regimens in the hospital should also be coordinated with plans for post-discharge medications and with the patient’s primary-care physician.

Two other concepts that often come up in discussions of opioid treatments are tolerance, which is a diminution of the drug’s effects over time, resulting in a need to increase doses of the medication to achieve the same analgesic effect, and physical dependence, in which the abrupt discontinuation of an analgesic after a period of continuous use causes physical symptoms of withdrawal from the drug. Both of these issues can be addressed with proper assessment and management, and neither is diagnostic of addiction.

Pain experts say tolerance, though a real phenomenon of opioids, is not often a serious problem with pain management in the hospital. Instead, the need for escalating analgesic doses may reflect changes in the underlying disease process. Tolerance can also include positive benefits such as its emergence for opioid side effects like nausea or sedation. Physical dependence on opioids is predictable but can be managed if the original cause of the pain is resolved and the analgesic is no longer needed. Most opioids can be gradually reduced, with each day’s dose at 75% of the previous day’s dose, until the drug is tapered off.6

What if the Patient Is an Addict?

Although pain experts believe that drug addiction caused by appropriate and adequate prescribing of opioids for analgesia is rare, this does not mean that hospitalists won’t face the problem of patients who are addicted to pain medications. “You are already treating patients with addiction,” said Dr. Crossno in his presentation at the AAHPM meeting in Salt Lake City.

Given that pre-existing addictions are relatively common in American society (estimates range from 5% to 17% of the population, depending on whether alcohol abuse is included), it is reasonable to expect this segment of the population will be represented among acutely ill, hospitalized patients.7 Sometimes, the substance abuse problem of a friend or family member affects the patient’s care, such as when pain medications are stolen from the patient.

“Some hospitalized patients do abuse opioids,” says Dr. Bekanich. “We catch people with drug paraphernalia or actually shooting up in their rooms.” Providers can exercise some control over what patients do in the hospital, but it is probably not realistic to expect that a hospitalist will be able to resolve long-standing substance abuse problems during the patient’s brief stay in the hospital.

As part of a comprehensive pain assessment, it is appropriate to ask if the patient has a history of drug use. Many patients will freely admit to such a history, may be actively in recovery or on a methadone maintenance program, or may even resist opioid analgesics despite severe pain because of their commitment to recovery. Without the benefit of such candor, however, it will be difficult to reach a conclusive diagnosis of drug addiction during the patient’s acute inpatient stay, because that ordinarily requires observations over time.

“It is not our job as hospitalists to get patients off opioids; there are other institutions and services for that,” Dr. Bekanich adds. “For us to try to do it in a few days in the hospital seems like a hopeless task. That is not to say we shouldn’t be mindful of the issues involved, talking to the patient or even offering a referral to a drug rehabilitation program. But we should not be trying to do drug rehab.”

The basic principles of believing patients’ reports of pain and providing analgesic doses sufficient to relieve the pain still apply—unless side effects or the patient’s problematic behavior demand a modification in this approach. Pain physicians often cite the maxim “trust but verify.” There are various screening tools that can be used for indicating the possibility of substance abuse, and it is imperative the use of controlled substances always be closely monitored.

Urine drug screening tests are easy to order in the hospital and may encourage compliance for patients who have a drug history when presented up front as a routine aspect of pain management. The urine test can detect prescribed medicines that are being taken by the patient as well as non-prescribed opioids, but it is important to be aware of false positives and negatives and opportunities for gaming the system by those who are determined to do so.

“Just as it is a myth that treating pain appropriately leads to addiction, it is also a myth that people with drug histories can’t have their pain treated effectively,” says Scott Irwin, MD, PhD, medical director of palliative care psychiatry at San Diego Hospice and Palliative Care. “The first thing to ask these patients is what are their goals for pain management. Get as much objective information as you can about the pain and the patient’s history. Fully inform the patient about options. Treat the pain just as you would for anyone else.”

Then, if things don’t add up, Dr. Irwin says, it may be necessary to go back and reassess the patient’s pain and history. Is there psychological distress? Perhaps the analgesic dose isn’t adequate. Maybe financial pressures or complicated social relationships are leading to drug diversion.

If the patient is participating in a methadone maintenance program or similar protocol, it is advisable for the hospitalist to speak to the medical director of that program. But effective pain control also supports maintenance. Emphasize long-acting analgesics, add non-opioid adjuvants and, when possible, find alternatives to intravenous administration. But if the patient is addicted, trying to minimize adverse effects from analgesic treatments might be the best the hospitalist can do.

Another approach to managing the patient with a history of drug abuse is the use of a contract or opioid agreement, in which the patient promises to do certain things with a clear understanding of the consequences for not doing so. Establish the rules early and be prepared to enforce them. Explain expectations for the patient and the physician’s role, designate a single pharmacy and a single physician responsible for pain prescribing, and get consent for treatment and drug testing. If a repeat offender breaks the agreement, it may be time to call in an addiction specialist. Such agreements should be negotiated in person by the physician, not delegated to nurses or other professionals, but then make sure other team members are in the loop. For an example of such an agreement, see http://tinyurl.com/y2bbh6.

Will Pain Medications Cause Respiratory Suppression?

Another common fear related to opioid use is that prescribing sufficient analgesic doses for patients with advanced illnesses could lead to toxicities, suppress their breathing, cause an overdose, or even prematurely end their lives. This scenario is often luridly presented as turning up the morphine drip. Pain management experts question the truth of this scenario, arguing that morphine often is falsely credited with deaths that result from advanced disease processes. Morphine is a common treatment for the sensation of dyspnea, while morphine-related toxicity likely will present with drowsiness, confusion, and loss of consciousness before respiratory compromise.8

A main concern of hospitalists is appreciating the need to balance pain relief with the side effects of analgesics, including opioid toxicities, which can be addressed through careful titration and frequent assessments. Respiratory suppression can be a side effect of opioids, and there are special groups of patients for whom any sedation is a major concern. An example is a lung transplant patient, for whom somnolence may suppress the important cough reflex.

Respiratory suppression from morphine is an area without a large evidence base. But a recent study of 725 patients nearing death in 13 hospice programs analyzed those who were receiving opioids and had at least one change in opioid dose prior to death to see if escalating opioid doses was associated with premature death.9 The authors conclude that “final opioid dose, but not percentage change in dose, was one of several factors associated with survival, but the association is very weak … (and explains) only a very small percentage in variation in survival.” They also found support for their conclusion that opioid use is not a major contributor to premature death in the few other published studies on the subject.

“I tell residents that the fear of respiratory suppression is overrated,” Dr. Youngwerth says. “As long as you follow World Health Organization and other recognized guidelines for dosing and titrating opioids, you can safely prescribe pain medications and control the patient’s pain. They get this fear ingrained during residency. In reality, it is not very common. I remind them that there is much more evidence of under-dosing.”

Dr. Bekanich describes a recent patient, a young woman suffering from severe abdominal pain following the birth of her baby. The pain was so difficult to manage that her hospital in rural Idaho transferred her to his medical center in Salt Lake City. She had also experienced respiratory arrest twice secondary to the application of fentanyl analgesic patches. “But she was relatively easy to manage once we tried a different drug, appropriately titrated,” he relates.

Dr. Bekanich spent two hours in the patient’s room adjusting the intravenous analgesic dose and monitoring the patient’s pulse oxygen level and neurological status. “These medicines don’t have to cause respiratory suppression, although it will happen occasionally, especially when there are multiple co-morbidities,” he says. “Hospitalists don’t realize that most of these problems can be avoided if you are meticulous in prescribing.”

Does Regulatory Scrutiny Chill Pain Treatment?

The ubiquitous fear of opioids and their potential side effects, including some unfounded or unrealistic fears, is also reflected in the regulation of controlled substances and physicians’ fears that they will be subjected to oppressive regulatory scrutiny.

Widely publicized cases of physicians being disciplined or prosecuted for over-prescribing opioids have only added to these fears, while the rare case of a physician being sued or sanctioned for under-prescribing pain medications does little to allay them.10

Growing attention to the inadequacies of and barriers to pain management—and the role of controlled substances regulation in those barriers—led to the 1998 promulgation of “Model Guidelines for the Use of Controlled Substances for the Treatment of Pain” by the Federation of State Medical Boards.11 These guidelines, promoting the legitimate role of opioids in relieving pain and acknowledging providers’ concerns about being disciplined, were revised in 2004 and have been adopted by 21 states.12

The effect remains, however. “For decades, physicians have reported being reluctant to prescribe opioids because of the fear of the stress, expense, and consequences of being investigated by licensing agencies or law enforcement,” states a 2006 state report card issued by the Pain & Policy Studies Group at the University of Wisconsin in Madison.13 “Some states—but far from all—have adopted policies which recognize that controlled substances are necessary for public health. … But in some states, pain treatment using opioids is unduly restricted by policies reflecting medical opinions that were discarded decades ago.”

The Pain & Policy Studies Group’s report card, which advocates for a balanced approach to the regulation and prescribing of controlled substances, has given every state a grade for how well it meets this goal. According to the 2006 report card, Michigan and Virginia get top grades for achieving balance in pain policy, while Georgia gets the lowest grade.

“Regulation is a real concern,” says Daniel Burkhardt, MD, associate professor and director of the Acute Pain Service at the University of California-San Francisco. “Every time a prosecutor arrests someone for prescribing too much pain medication, these things travel, adding to the extra regulatory burden on physicians.”

Carol Jessop, MD, a hospitalist and palliative care consultant at Alta Bates Summit Medical Center in Berkeley, Calif., says the burden has lessened somewhat in California because that state eliminated its requirements for triplicate paper prescribing forms for controlled substances.

A related concern involves the potential diversion of controlled substances by impaired healthcare professionals for personal use and abuse. This is another of the fears that have driven archaic pain regulation in many states. In fact, current estimates suggest that a substance abuse-related impairment will affect between 8% and 18% percent of physicians sometime in their lives, and that 2% of physicians are dealing with an active substance abuse problem.14

A recent medical journal letter to the editor from the Wisconsin Pain & Policy Studies Group suggests public policies on opioid diversion should focus more on sources of diversion such as “thefts, including armed robberies, night break-ins, and employee and customer pilferage,” rather than just the doctor-patient prescribing relationship.15

Physician diversion data don’t break out hospital medicine as a category, but some hospitalists say they have not heard of diversion problems involving hospitalist colleagues. That may reflect the fact that hospitalists, unlike some other health professionals, generally don’t administer controlled substances directly to the patient or have ready access to hospital drug storage facilities. TH

Larry Beresford is a regular contributor to The Hospitalist.

References

1. Joranson D, Payne R. Will my pain be managed? In Improving End-of-Life Care: The Role of Attorneys General. National Association of Attorneys General. Washington, D.C. 2003. Available at www.naag.org/end-of-life_healthcare.php. Last accessed April 13, 2007.
2. American Pain Society. Definitions related to the use of opioids for the treatment of pain: a consensus document from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine. Available at www.ampainsoc.org/advocacy/opioids2.htm. Last accessed April 13, 2007.
3. Weissman DE, Haddox JD. Opioid pseudoaddiction. Pain. 1989 Mar;36(3):363-366.
4. Weissman DE. Fast Fact and Concept #68: Is it pain or addiction? [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_68.htm. Last accessed April 13, 2007.
5. Weissman DE. Fast Fact and Concept #69: Pseudoaddiction. [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_69.htm. Last accessed April 13, 2007.
6. Doyle D, Hanks G, Cherny N, et al, eds. The Oxford Textbook of Palliative Medicine. 3rd ed. Oxford, England: Oxford University Press;2005:336.
7. Passik SD, Kirsh KL. Chapter 56: Pain in patients with alcohol and drug dependence. In Bruera E, Higginson I, von Gunten C, et al. Textbook of Palliative Medicine. London, England: Hodder Arnold;2006:517-524.
8. Von Gunten CF. Fast Fact and Concept #8: Morphine and hastened death. [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_008.htm. Last accessed April 13, 2007.
9. Portenoy RK, Siberceva U, Smout R, et al. Opioid use and survival at the end of life: a survey of a hospice population. J Pain Symptom Manage. 2006;32:532-540.
10. Warm EJ, Weissman DE. Fast Fact and Concept #63: The legal liability of under-treatment of pain. [The End of Life/Palliative Education Resource Center.] Available at: www.eperc.mcw.edu/fastFact/ff_63.htm. Last accessed April 13, 2007.
11. Federation of the State Medical Boards of the United States. Dallas, Texas. Available at www.fsmb.org. Accessed April 13, 2007.
12. National Association of Attorneys General. Improving End-of-Life Care: The Role of Attorneys General. National Association of Attorneys General. Washington, D.C. 2003. Available at www.naag.org/end-of-life_healthcare.php. Last accessed April 13, 2007.
13. Pain & Policy Studies Group. University of Wisconsin Paul P. Carbone Comprehensive Cancer Center. Available at: www.painpolicy.wisc.edu. Accessed April 13, 2007.
14. Blondell RD. Taking a proactive approach to physician impairment. Postgrad Med. 2005 Jul;118(1):16-18.
15. Joranson DE, Gilson AM. Drug crime is a source of abused pain medications in the United States. J Pain Symptom Manage. 2005 Oct;30(4):299-301.

Note: This is Part 2 of The Hospitalist’s series on pain and hospital medicine. Part 1 appeared on p. 45 of the April issue.

Welcome to Part 2 of our three-part series on managing the pain of hospitalized patients. Last month’s article presented the context for pain management in the hospital—a core competency identified by SHM. It emphasized techniques for assessing patients’ pain, ranging from a zero-to-10 pain score to more complex pain histories addressing type, source, duration, and intensity as well as psychosocial and spiritual factors.

Part 2 delves into some difficult cases and dilemmas of pain management—situations that can take hospitalists out of their comfort zone and challenge their confidence in managing their patients’ pain.

Some of these dilemmas arise from misconceptions about pain and pain treatments and from the fact that, historically, physicians have not been well trained in optimal pain management. General barriers to pain management in the U.S. healthcare system, as identified by the National Association of Attorneys General, include patients’ beliefs, physician and institutional practices, restrictive state polices, and racial and socioeconomic disparities.1

Many of these issues relate specifically to the most common treatments for severe pain, opioid analgesics, which have all sorts of negative associations based on misconceptions about abuse, addiction, and overdose. In other cases, physicians face real challenges in balancing analgesic benefits with side effects and in determining the right medication, dose, and schedule to meet the patient’s need for pain relief.

Hospitalists confronting difficult pain cases work under the added pressure of trying to bring their patients’ acute illnesses under control so they can discharge them to a lower level of care as soon as prudently possible. This time pressure, along with demands arising from the rest of the hospitalist’s caseload, may impose limits on what can be accomplished in difficult situations or with medications that require time to stabilize.

Challenges also arise when the customary approach to pain management—the drug and dosing schedule the hospitalist is most comfortable using for most patients—fails to bring the pain under control. This is often a red flag for the need to try something new, says Stephen Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and a consultant on the medical center’s palliative care service. In some cases, that means calling in a specialist in pain treatment, palliative medicine, psychiatry, or substance abuse.

“You need to work into the equation that there are pitfalls and caveats to everything we say about pain,” Dr. Bekanich observes. “Plus, the common pain treatments are controlled substances, with obvious legal implications and a professional duty for physicians to handle them safely and appropriately.”

When Dr. Bekanich finds himself confronting a difficult pain situation that has caused a conflict with a patient, he often involves one of the hospital’s customer service patient advocates. They are trained to mediate disagreements between patients and the treatment team.

Is This Patient’s Pain Real?

Physicians sometimes wonder if their patients’ reports of pain are accurate. Is the pain really as bad as the patient says it is? “Residents, frequently, are more skeptical of patients’ claims of pain, doubting whether they are truly experiencing that level of pain,” reports Jean Youngwerth, MD, a hospitalist, palliative care consultant, and fellowship associate program director at the University of Colorado Health Sciences Center in Aurora.

“I tell my residents that malingering is rare, and those few cases where it happens really tend to stand out,” Dr. Young­werth says. “I also tell them that our default position is always to trust the patient, unless given a good reason not to. I have been burned more often when I questioned my patients’ reports of pain than when I didn’t.”

Pain experts emphasize that the patient’s self-report is the most reliable source of information on pain—based on an understanding of pain as a complex, subjective phenomenon associated with actual or potential tissue damage and the patient’s perception of and emotional reaction to that sensation. The phenomenon of pain also includes emotional, social, psychological, even spiritual components and can be mediated by a host of other factors. But that doesn’t mean it isn’t real to the patient.

“Often, younger physicians take the attitude that if the pain is real, then administration of morphine will make it go away,” says Porter Storey, MD, FACP, FAAHPM. “In reality, pain doesn’t always respond to opioids, for all sorts of reasons. Hospitalists value clarity, and they use pain as a screen for all sorts of other problems. Their goal, often, is not so much the comfort of the patient as it is diagnosing, treating, and then discharging the patient from the hospital.” Dr. Storey is a palliative care physician in Boulder, Colo., and executive vice president for Medical Affairs at the American Academy of Hospice and Palliative Medicine (AAHPM).

Physicians need to be reminded, however, that unresolved pain in hospitalized patients has many negative consequences. These range from resistance to rehabilitation to depression to delayed hospital discharge, as well as reduced job satisfaction for the healthcare professionals who care for them.

Will Prescribing Analgesics Cause Addiction?

Fears about causing addiction haunt many pain management discussions. Requests for more medications, obsessing over the next scheduled analgesic dose, and even manipulative or drug-seeking behaviors can be misunderstood by physicians who lack training in the real nature of drug addiction. Actual cases of drug addiction created by appropriate, sufficient, and well-monitored opioid analgesic treatment are rare, pain experts say. There is an important caveat: the patient who brings a prior history of drug abuse to the current acute medical episode.

“There are no good data about iatrogenic addiction,” says Robert Brody, MD, chief of the pain consultation clinic at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. “People who do pain management, certainly including hospice and palliative care physicians, don’t really believe in it. In my own clinical experience, most patients don’t like pain medications and stop them as soon as they can.”

Addiction is more accurately understood as the inappropriate use of a drug for non-medical purposes. It refers to disruptive, drug-seeking behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.2 Addiction experts also describe addiction as a disease syndrome in its own right. Although that concept can sometimes be hard to accept by those who don’t have a lot of experience working with it, it is a useful paradigm to treat addiction as if it were a disease, says Ronald Crossno, MD, Rockdale, Texas-based area medical director for the VistaCare hospice chain.

Pain experts use the term pseudoaddiction for behaviors that are reminiscent of addiction but in fact reflect the pursuit of pain relief. Examples might include hoarding drugs, clock-watching, and exaggerated complaints of pain, such as moaning or crying. If it is pseudoaddiction, once the pain is brought under control, these behaviors cease. The term was coined in 1989 to describe an iatrogenic syndrome resulting from poorly treated pain.3-5

“Pseudoaddiction is a term you need to know,” Dr. Crossno asserted during a presentation on addiction pain at the recent annual conference of AAHPM in Salt Lake City in February. “It is at least as prevalent as addiction—and an indictment of how our healthcare system deals with pain.”

Dr. Youngwerth offers some advice.“We often see pseudoaddiction in response to undertreatment and inadequately managed pain,” she says. “If you treat the pain appropriately, these behaviors go away.” She tries to teach this concept to residents and hospital staff, who sometimes find it hard to put themselves in the shoes of patients experiencing severe pain.

“If you have a 68-year-old patient with no history of addiction or substance abuse who is in the hospital [with the] status post-hip replacement and is now clock-watching and routinely pressing the call button before her next dose of opioids is due, staff may feel that she is displaying addictive behaviors,” Dr. Youngwerth says. “Why would they think that this situation evolved into addiction during her brief hospital stay? It’s more likely that she’s just afraid of having pain.”

The solution to pseudoaddiction is to prescribe opioids at pharmacologically appropriate doses and schedules. Then, titrate up until analgesia is achieved or toxicities necessitate alternative approaches. Use all the techniques described in the first article of this series. It is also important to restore trust and the patient’s confidence in the medical system’s ability to manage his or her pain. Opioid pain regimens in the hospital should also be coordinated with plans for post-discharge medications and with the patient’s primary-care physician.

Two other concepts that often come up in discussions of opioid treatments are tolerance, which is a diminution of the drug’s effects over time, resulting in a need to increase doses of the medication to achieve the same analgesic effect, and physical dependence, in which the abrupt discontinuation of an analgesic after a period of continuous use causes physical symptoms of withdrawal from the drug. Both of these issues can be addressed with proper assessment and management, and neither is diagnostic of addiction.

Pain experts say tolerance, though a real phenomenon of opioids, is not often a serious problem with pain management in the hospital. Instead, the need for escalating analgesic doses may reflect changes in the underlying disease process. Tolerance can also include positive benefits such as its emergence for opioid side effects like nausea or sedation. Physical dependence on opioids is predictable but can be managed if the original cause of the pain is resolved and the analgesic is no longer needed. Most opioids can be gradually reduced, with each day’s dose at 75% of the previous day’s dose, until the drug is tapered off.6

What if the Patient Is an Addict?

Although pain experts believe that drug addiction caused by appropriate and adequate prescribing of opioids for analgesia is rare, this does not mean that hospitalists won’t face the problem of patients who are addicted to pain medications. “You are already treating patients with addiction,” said Dr. Crossno in his presentation at the AAHPM meeting in Salt Lake City.

Given that pre-existing addictions are relatively common in American society (estimates range from 5% to 17% of the population, depending on whether alcohol abuse is included), it is reasonable to expect this segment of the population will be represented among acutely ill, hospitalized patients.7 Sometimes, the substance abuse problem of a friend or family member affects the patient’s care, such as when pain medications are stolen from the patient.

“Some hospitalized patients do abuse opioids,” says Dr. Bekanich. “We catch people with drug paraphernalia or actually shooting up in their rooms.” Providers can exercise some control over what patients do in the hospital, but it is probably not realistic to expect that a hospitalist will be able to resolve long-standing substance abuse problems during the patient’s brief stay in the hospital.

As part of a comprehensive pain assessment, it is appropriate to ask if the patient has a history of drug use. Many patients will freely admit to such a history, may be actively in recovery or on a methadone maintenance program, or may even resist opioid analgesics despite severe pain because of their commitment to recovery. Without the benefit of such candor, however, it will be difficult to reach a conclusive diagnosis of drug addiction during the patient’s acute inpatient stay, because that ordinarily requires observations over time.

“It is not our job as hospitalists to get patients off opioids; there are other institutions and services for that,” Dr. Bekanich adds. “For us to try to do it in a few days in the hospital seems like a hopeless task. That is not to say we shouldn’t be mindful of the issues involved, talking to the patient or even offering a referral to a drug rehabilitation program. But we should not be trying to do drug rehab.”

The basic principles of believing patients’ reports of pain and providing analgesic doses sufficient to relieve the pain still apply—unless side effects or the patient’s problematic behavior demand a modification in this approach. Pain physicians often cite the maxim “trust but verify.” There are various screening tools that can be used for indicating the possibility of substance abuse, and it is imperative the use of controlled substances always be closely monitored.

Urine drug screening tests are easy to order in the hospital and may encourage compliance for patients who have a drug history when presented up front as a routine aspect of pain management. The urine test can detect prescribed medicines that are being taken by the patient as well as non-prescribed opioids, but it is important to be aware of false positives and negatives and opportunities for gaming the system by those who are determined to do so.

“Just as it is a myth that treating pain appropriately leads to addiction, it is also a myth that people with drug histories can’t have their pain treated effectively,” says Scott Irwin, MD, PhD, medical director of palliative care psychiatry at San Diego Hospice and Palliative Care. “The first thing to ask these patients is what are their goals for pain management. Get as much objective information as you can about the pain and the patient’s history. Fully inform the patient about options. Treat the pain just as you would for anyone else.”

Then, if things don’t add up, Dr. Irwin says, it may be necessary to go back and reassess the patient’s pain and history. Is there psychological distress? Perhaps the analgesic dose isn’t adequate. Maybe financial pressures or complicated social relationships are leading to drug diversion.

If the patient is participating in a methadone maintenance program or similar protocol, it is advisable for the hospitalist to speak to the medical director of that program. But effective pain control also supports maintenance. Emphasize long-acting analgesics, add non-opioid adjuvants and, when possible, find alternatives to intravenous administration. But if the patient is addicted, trying to minimize adverse effects from analgesic treatments might be the best the hospitalist can do.

Another approach to managing the patient with a history of drug abuse is the use of a contract or opioid agreement, in which the patient promises to do certain things with a clear understanding of the consequences for not doing so. Establish the rules early and be prepared to enforce them. Explain expectations for the patient and the physician’s role, designate a single pharmacy and a single physician responsible for pain prescribing, and get consent for treatment and drug testing. If a repeat offender breaks the agreement, it may be time to call in an addiction specialist. Such agreements should be negotiated in person by the physician, not delegated to nurses or other professionals, but then make sure other team members are in the loop. For an example of such an agreement, see http://tinyurl.com/y2bbh6.

Will Pain Medications Cause Respiratory Suppression?

Another common fear related to opioid use is that prescribing sufficient analgesic doses for patients with advanced illnesses could lead to toxicities, suppress their breathing, cause an overdose, or even prematurely end their lives. This scenario is often luridly presented as turning up the morphine drip. Pain management experts question the truth of this scenario, arguing that morphine often is falsely credited with deaths that result from advanced disease processes. Morphine is a common treatment for the sensation of dyspnea, while morphine-related toxicity likely will present with drowsiness, confusion, and loss of consciousness before respiratory compromise.8

A main concern of hospitalists is appreciating the need to balance pain relief with the side effects of analgesics, including opioid toxicities, which can be addressed through careful titration and frequent assessments. Respiratory suppression can be a side effect of opioids, and there are special groups of patients for whom any sedation is a major concern. An example is a lung transplant patient, for whom somnolence may suppress the important cough reflex.

Respiratory suppression from morphine is an area without a large evidence base. But a recent study of 725 patients nearing death in 13 hospice programs analyzed those who were receiving opioids and had at least one change in opioid dose prior to death to see if escalating opioid doses was associated with premature death.9 The authors conclude that “final opioid dose, but not percentage change in dose, was one of several factors associated with survival, but the association is very weak … (and explains) only a very small percentage in variation in survival.” They also found support for their conclusion that opioid use is not a major contributor to premature death in the few other published studies on the subject.

“I tell residents that the fear of respiratory suppression is overrated,” Dr. Youngwerth says. “As long as you follow World Health Organization and other recognized guidelines for dosing and titrating opioids, you can safely prescribe pain medications and control the patient’s pain. They get this fear ingrained during residency. In reality, it is not very common. I remind them that there is much more evidence of under-dosing.”

Dr. Bekanich describes a recent patient, a young woman suffering from severe abdominal pain following the birth of her baby. The pain was so difficult to manage that her hospital in rural Idaho transferred her to his medical center in Salt Lake City. She had also experienced respiratory arrest twice secondary to the application of fentanyl analgesic patches. “But she was relatively easy to manage once we tried a different drug, appropriately titrated,” he relates.

Dr. Bekanich spent two hours in the patient’s room adjusting the intravenous analgesic dose and monitoring the patient’s pulse oxygen level and neurological status. “These medicines don’t have to cause respiratory suppression, although it will happen occasionally, especially when there are multiple co-morbidities,” he says. “Hospitalists don’t realize that most of these problems can be avoided if you are meticulous in prescribing.”

Does Regulatory Scrutiny Chill Pain Treatment?

The ubiquitous fear of opioids and their potential side effects, including some unfounded or unrealistic fears, is also reflected in the regulation of controlled substances and physicians’ fears that they will be subjected to oppressive regulatory scrutiny.

Widely publicized cases of physicians being disciplined or prosecuted for over-prescribing opioids have only added to these fears, while the rare case of a physician being sued or sanctioned for under-prescribing pain medications does little to allay them.10

Growing attention to the inadequacies of and barriers to pain management—and the role of controlled substances regulation in those barriers—led to the 1998 promulgation of “Model Guidelines for the Use of Controlled Substances for the Treatment of Pain” by the Federation of State Medical Boards.11 These guidelines, promoting the legitimate role of opioids in relieving pain and acknowledging providers’ concerns about being disciplined, were revised in 2004 and have been adopted by 21 states.12

The effect remains, however. “For decades, physicians have reported being reluctant to prescribe opioids because of the fear of the stress, expense, and consequences of being investigated by licensing agencies or law enforcement,” states a 2006 state report card issued by the Pain & Policy Studies Group at the University of Wisconsin in Madison.13 “Some states—but far from all—have adopted policies which recognize that controlled substances are necessary for public health. … But in some states, pain treatment using opioids is unduly restricted by policies reflecting medical opinions that were discarded decades ago.”

The Pain & Policy Studies Group’s report card, which advocates for a balanced approach to the regulation and prescribing of controlled substances, has given every state a grade for how well it meets this goal. According to the 2006 report card, Michigan and Virginia get top grades for achieving balance in pain policy, while Georgia gets the lowest grade.

“Regulation is a real concern,” says Daniel Burkhardt, MD, associate professor and director of the Acute Pain Service at the University of California-San Francisco. “Every time a prosecutor arrests someone for prescribing too much pain medication, these things travel, adding to the extra regulatory burden on physicians.”

Carol Jessop, MD, a hospitalist and palliative care consultant at Alta Bates Summit Medical Center in Berkeley, Calif., says the burden has lessened somewhat in California because that state eliminated its requirements for triplicate paper prescribing forms for controlled substances.

A related concern involves the potential diversion of controlled substances by impaired healthcare professionals for personal use and abuse. This is another of the fears that have driven archaic pain regulation in many states. In fact, current estimates suggest that a substance abuse-related impairment will affect between 8% and 18% percent of physicians sometime in their lives, and that 2% of physicians are dealing with an active substance abuse problem.14

A recent medical journal letter to the editor from the Wisconsin Pain & Policy Studies Group suggests public policies on opioid diversion should focus more on sources of diversion such as “thefts, including armed robberies, night break-ins, and employee and customer pilferage,” rather than just the doctor-patient prescribing relationship.15

Physician diversion data don’t break out hospital medicine as a category, but some hospitalists say they have not heard of diversion problems involving hospitalist colleagues. That may reflect the fact that hospitalists, unlike some other health professionals, generally don’t administer controlled substances directly to the patient or have ready access to hospital drug storage facilities. TH

Larry Beresford is a regular contributor to The Hospitalist.

References

1. Joranson D, Payne R. Will my pain be managed? In Improving End-of-Life Care: The Role of Attorneys General. National Association of Attorneys General. Washington, D.C. 2003. Available at www.naag.org/end-of-life_healthcare.php. Last accessed April 13, 2007.
2. American Pain Society. Definitions related to the use of opioids for the treatment of pain: a consensus document from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine. Available at www.ampainsoc.org/advocacy/opioids2.htm. Last accessed April 13, 2007.
3. Weissman DE, Haddox JD. Opioid pseudoaddiction. Pain. 1989 Mar;36(3):363-366.
4. Weissman DE. Fast Fact and Concept #68: Is it pain or addiction? [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_68.htm. Last accessed April 13, 2007.
5. Weissman DE. Fast Fact and Concept #69: Pseudoaddiction. [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_69.htm. Last accessed April 13, 2007.
6. Doyle D, Hanks G, Cherny N, et al, eds. The Oxford Textbook of Palliative Medicine. 3rd ed. Oxford, England: Oxford University Press;2005:336.
7. Passik SD, Kirsh KL. Chapter 56: Pain in patients with alcohol and drug dependence. In Bruera E, Higginson I, von Gunten C, et al. Textbook of Palliative Medicine. London, England: Hodder Arnold;2006:517-524.
8. Von Gunten CF. Fast Fact and Concept #8: Morphine and hastened death. [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_008.htm. Last accessed April 13, 2007.
9. Portenoy RK, Siberceva U, Smout R, et al. Opioid use and survival at the end of life: a survey of a hospice population. J Pain Symptom Manage. 2006;32:532-540.
10. Warm EJ, Weissman DE. Fast Fact and Concept #63: The legal liability of under-treatment of pain. [The End of Life/Palliative Education Resource Center.] Available at: www.eperc.mcw.edu/fastFact/ff_63.htm. Last accessed April 13, 2007.
11. Federation of the State Medical Boards of the United States. Dallas, Texas. Available at www.fsmb.org. Accessed April 13, 2007.
12. National Association of Attorneys General. Improving End-of-Life Care: The Role of Attorneys General. National Association of Attorneys General. Washington, D.C. 2003. Available at www.naag.org/end-of-life_healthcare.php. Last accessed April 13, 2007.
13. Pain & Policy Studies Group. University of Wisconsin Paul P. Carbone Comprehensive Cancer Center. Available at: www.painpolicy.wisc.edu. Accessed April 13, 2007.
14. Blondell RD. Taking a proactive approach to physician impairment. Postgrad Med. 2005 Jul;118(1):16-18.
15. Joranson DE, Gilson AM. Drug crime is a source of abused pain medications in the United States. J Pain Symptom Manage. 2005 Oct;30(4):299-301.

Note: This is Part 2 of The Hospitalist’s series on pain and hospital medicine. Part 1 appeared on p. 45 of the April issue.

Welcome to Part 2 of our three-part series on managing the pain of hospitalized patients. Last month’s article presented the context for pain management in the hospital—a core competency identified by SHM. It emphasized techniques for assessing patients’ pain, ranging from a zero-to-10 pain score to more complex pain histories addressing type, source, duration, and intensity as well as psychosocial and spiritual factors.

Part 2 delves into some difficult cases and dilemmas of pain management—situations that can take hospitalists out of their comfort zone and challenge their confidence in managing their patients’ pain.

Some of these dilemmas arise from misconceptions about pain and pain treatments and from the fact that, historically, physicians have not been well trained in optimal pain management. General barriers to pain management in the U.S. healthcare system, as identified by the National Association of Attorneys General, include patients’ beliefs, physician and institutional practices, restrictive state polices, and racial and socioeconomic disparities.1

Many of these issues relate specifically to the most common treatments for severe pain, opioid analgesics, which have all sorts of negative associations based on misconceptions about abuse, addiction, and overdose. In other cases, physicians face real challenges in balancing analgesic benefits with side effects and in determining the right medication, dose, and schedule to meet the patient’s need for pain relief.

Hospitalists confronting difficult pain cases work under the added pressure of trying to bring their patients’ acute illnesses under control so they can discharge them to a lower level of care as soon as prudently possible. This time pressure, along with demands arising from the rest of the hospitalist’s caseload, may impose limits on what can be accomplished in difficult situations or with medications that require time to stabilize.

Challenges also arise when the customary approach to pain management—the drug and dosing schedule the hospitalist is most comfortable using for most patients—fails to bring the pain under control. This is often a red flag for the need to try something new, says Stephen Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and a consultant on the medical center’s palliative care service. In some cases, that means calling in a specialist in pain treatment, palliative medicine, psychiatry, or substance abuse.

“You need to work into the equation that there are pitfalls and caveats to everything we say about pain,” Dr. Bekanich observes. “Plus, the common pain treatments are controlled substances, with obvious legal implications and a professional duty for physicians to handle them safely and appropriately.”

When Dr. Bekanich finds himself confronting a difficult pain situation that has caused a conflict with a patient, he often involves one of the hospital’s customer service patient advocates. They are trained to mediate disagreements between patients and the treatment team.

Is This Patient’s Pain Real?

Physicians sometimes wonder if their patients’ reports of pain are accurate. Is the pain really as bad as the patient says it is? “Residents, frequently, are more skeptical of patients’ claims of pain, doubting whether they are truly experiencing that level of pain,” reports Jean Youngwerth, MD, a hospitalist, palliative care consultant, and fellowship associate program director at the University of Colorado Health Sciences Center in Aurora.

“I tell my residents that malingering is rare, and those few cases where it happens really tend to stand out,” Dr. Young­werth says. “I also tell them that our default position is always to trust the patient, unless given a good reason not to. I have been burned more often when I questioned my patients’ reports of pain than when I didn’t.”

Pain experts emphasize that the patient’s self-report is the most reliable source of information on pain—based on an understanding of pain as a complex, subjective phenomenon associated with actual or potential tissue damage and the patient’s perception of and emotional reaction to that sensation. The phenomenon of pain also includes emotional, social, psychological, even spiritual components and can be mediated by a host of other factors. But that doesn’t mean it isn’t real to the patient.

“Often, younger physicians take the attitude that if the pain is real, then administration of morphine will make it go away,” says Porter Storey, MD, FACP, FAAHPM. “In reality, pain doesn’t always respond to opioids, for all sorts of reasons. Hospitalists value clarity, and they use pain as a screen for all sorts of other problems. Their goal, often, is not so much the comfort of the patient as it is diagnosing, treating, and then discharging the patient from the hospital.” Dr. Storey is a palliative care physician in Boulder, Colo., and executive vice president for Medical Affairs at the American Academy of Hospice and Palliative Medicine (AAHPM).

Physicians need to be reminded, however, that unresolved pain in hospitalized patients has many negative consequences. These range from resistance to rehabilitation to depression to delayed hospital discharge, as well as reduced job satisfaction for the healthcare professionals who care for them.

Will Prescribing Analgesics Cause Addiction?

Fears about causing addiction haunt many pain management discussions. Requests for more medications, obsessing over the next scheduled analgesic dose, and even manipulative or drug-seeking behaviors can be misunderstood by physicians who lack training in the real nature of drug addiction. Actual cases of drug addiction created by appropriate, sufficient, and well-monitored opioid analgesic treatment are rare, pain experts say. There is an important caveat: the patient who brings a prior history of drug abuse to the current acute medical episode.

“There are no good data about iatrogenic addiction,” says Robert Brody, MD, chief of the pain consultation clinic at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. “People who do pain management, certainly including hospice and palliative care physicians, don’t really believe in it. In my own clinical experience, most patients don’t like pain medications and stop them as soon as they can.”

Addiction is more accurately understood as the inappropriate use of a drug for non-medical purposes. It refers to disruptive, drug-seeking behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.2 Addiction experts also describe addiction as a disease syndrome in its own right. Although that concept can sometimes be hard to accept by those who don’t have a lot of experience working with it, it is a useful paradigm to treat addiction as if it were a disease, says Ronald Crossno, MD, Rockdale, Texas-based area medical director for the VistaCare hospice chain.

Pain experts use the term pseudoaddiction for behaviors that are reminiscent of addiction but in fact reflect the pursuit of pain relief. Examples might include hoarding drugs, clock-watching, and exaggerated complaints of pain, such as moaning or crying. If it is pseudoaddiction, once the pain is brought under control, these behaviors cease. The term was coined in 1989 to describe an iatrogenic syndrome resulting from poorly treated pain.3-5

“Pseudoaddiction is a term you need to know,” Dr. Crossno asserted during a presentation on addiction pain at the recent annual conference of AAHPM in Salt Lake City in February. “It is at least as prevalent as addiction—and an indictment of how our healthcare system deals with pain.”

Dr. Youngwerth offers some advice.“We often see pseudoaddiction in response to undertreatment and inadequately managed pain,” she says. “If you treat the pain appropriately, these behaviors go away.” She tries to teach this concept to residents and hospital staff, who sometimes find it hard to put themselves in the shoes of patients experiencing severe pain.

“If you have a 68-year-old patient with no history of addiction or substance abuse who is in the hospital [with the] status post-hip replacement and is now clock-watching and routinely pressing the call button before her next dose of opioids is due, staff may feel that she is displaying addictive behaviors,” Dr. Youngwerth says. “Why would they think that this situation evolved into addiction during her brief hospital stay? It’s more likely that she’s just afraid of having pain.”

The solution to pseudoaddiction is to prescribe opioids at pharmacologically appropriate doses and schedules. Then, titrate up until analgesia is achieved or toxicities necessitate alternative approaches. Use all the techniques described in the first article of this series. It is also important to restore trust and the patient’s confidence in the medical system’s ability to manage his or her pain. Opioid pain regimens in the hospital should also be coordinated with plans for post-discharge medications and with the patient’s primary-care physician.

Two other concepts that often come up in discussions of opioid treatments are tolerance, which is a diminution of the drug’s effects over time, resulting in a need to increase doses of the medication to achieve the same analgesic effect, and physical dependence, in which the abrupt discontinuation of an analgesic after a period of continuous use causes physical symptoms of withdrawal from the drug. Both of these issues can be addressed with proper assessment and management, and neither is diagnostic of addiction.

Pain experts say tolerance, though a real phenomenon of opioids, is not often a serious problem with pain management in the hospital. Instead, the need for escalating analgesic doses may reflect changes in the underlying disease process. Tolerance can also include positive benefits such as its emergence for opioid side effects like nausea or sedation. Physical dependence on opioids is predictable but can be managed if the original cause of the pain is resolved and the analgesic is no longer needed. Most opioids can be gradually reduced, with each day’s dose at 75% of the previous day’s dose, until the drug is tapered off.6

What if the Patient Is an Addict?

Although pain experts believe that drug addiction caused by appropriate and adequate prescribing of opioids for analgesia is rare, this does not mean that hospitalists won’t face the problem of patients who are addicted to pain medications. “You are already treating patients with addiction,” said Dr. Crossno in his presentation at the AAHPM meeting in Salt Lake City.

Given that pre-existing addictions are relatively common in American society (estimates range from 5% to 17% of the population, depending on whether alcohol abuse is included), it is reasonable to expect this segment of the population will be represented among acutely ill, hospitalized patients.7 Sometimes, the substance abuse problem of a friend or family member affects the patient’s care, such as when pain medications are stolen from the patient.

“Some hospitalized patients do abuse opioids,” says Dr. Bekanich. “We catch people with drug paraphernalia or actually shooting up in their rooms.” Providers can exercise some control over what patients do in the hospital, but it is probably not realistic to expect that a hospitalist will be able to resolve long-standing substance abuse problems during the patient’s brief stay in the hospital.

As part of a comprehensive pain assessment, it is appropriate to ask if the patient has a history of drug use. Many patients will freely admit to such a history, may be actively in recovery or on a methadone maintenance program, or may even resist opioid analgesics despite severe pain because of their commitment to recovery. Without the benefit of such candor, however, it will be difficult to reach a conclusive diagnosis of drug addiction during the patient’s acute inpatient stay, because that ordinarily requires observations over time.

“It is not our job as hospitalists to get patients off opioids; there are other institutions and services for that,” Dr. Bekanich adds. “For us to try to do it in a few days in the hospital seems like a hopeless task. That is not to say we shouldn’t be mindful of the issues involved, talking to the patient or even offering a referral to a drug rehabilitation program. But we should not be trying to do drug rehab.”

The basic principles of believing patients’ reports of pain and providing analgesic doses sufficient to relieve the pain still apply—unless side effects or the patient’s problematic behavior demand a modification in this approach. Pain physicians often cite the maxim “trust but verify.” There are various screening tools that can be used for indicating the possibility of substance abuse, and it is imperative the use of controlled substances always be closely monitored.

Urine drug screening tests are easy to order in the hospital and may encourage compliance for patients who have a drug history when presented up front as a routine aspect of pain management. The urine test can detect prescribed medicines that are being taken by the patient as well as non-prescribed opioids, but it is important to be aware of false positives and negatives and opportunities for gaming the system by those who are determined to do so.

“Just as it is a myth that treating pain appropriately leads to addiction, it is also a myth that people with drug histories can’t have their pain treated effectively,” says Scott Irwin, MD, PhD, medical director of palliative care psychiatry at San Diego Hospice and Palliative Care. “The first thing to ask these patients is what are their goals for pain management. Get as much objective information as you can about the pain and the patient’s history. Fully inform the patient about options. Treat the pain just as you would for anyone else.”

Then, if things don’t add up, Dr. Irwin says, it may be necessary to go back and reassess the patient’s pain and history. Is there psychological distress? Perhaps the analgesic dose isn’t adequate. Maybe financial pressures or complicated social relationships are leading to drug diversion.

If the patient is participating in a methadone maintenance program or similar protocol, it is advisable for the hospitalist to speak to the medical director of that program. But effective pain control also supports maintenance. Emphasize long-acting analgesics, add non-opioid adjuvants and, when possible, find alternatives to intravenous administration. But if the patient is addicted, trying to minimize adverse effects from analgesic treatments might be the best the hospitalist can do.

Another approach to managing the patient with a history of drug abuse is the use of a contract or opioid agreement, in which the patient promises to do certain things with a clear understanding of the consequences for not doing so. Establish the rules early and be prepared to enforce them. Explain expectations for the patient and the physician’s role, designate a single pharmacy and a single physician responsible for pain prescribing, and get consent for treatment and drug testing. If a repeat offender breaks the agreement, it may be time to call in an addiction specialist. Such agreements should be negotiated in person by the physician, not delegated to nurses or other professionals, but then make sure other team members are in the loop. For an example of such an agreement, see http://tinyurl.com/y2bbh6.

Will Pain Medications Cause Respiratory Suppression?

Another common fear related to opioid use is that prescribing sufficient analgesic doses for patients with advanced illnesses could lead to toxicities, suppress their breathing, cause an overdose, or even prematurely end their lives. This scenario is often luridly presented as turning up the morphine drip. Pain management experts question the truth of this scenario, arguing that morphine often is falsely credited with deaths that result from advanced disease processes. Morphine is a common treatment for the sensation of dyspnea, while morphine-related toxicity likely will present with drowsiness, confusion, and loss of consciousness before respiratory compromise.8

A main concern of hospitalists is appreciating the need to balance pain relief with the side effects of analgesics, including opioid toxicities, which can be addressed through careful titration and frequent assessments. Respiratory suppression can be a side effect of opioids, and there are special groups of patients for whom any sedation is a major concern. An example is a lung transplant patient, for whom somnolence may suppress the important cough reflex.

Respiratory suppression from morphine is an area without a large evidence base. But a recent study of 725 patients nearing death in 13 hospice programs analyzed those who were receiving opioids and had at least one change in opioid dose prior to death to see if escalating opioid doses was associated with premature death.9 The authors conclude that “final opioid dose, but not percentage change in dose, was one of several factors associated with survival, but the association is very weak … (and explains) only a very small percentage in variation in survival.” They also found support for their conclusion that opioid use is not a major contributor to premature death in the few other published studies on the subject.

“I tell residents that the fear of respiratory suppression is overrated,” Dr. Youngwerth says. “As long as you follow World Health Organization and other recognized guidelines for dosing and titrating opioids, you can safely prescribe pain medications and control the patient’s pain. They get this fear ingrained during residency. In reality, it is not very common. I remind them that there is much more evidence of under-dosing.”

Dr. Bekanich describes a recent patient, a young woman suffering from severe abdominal pain following the birth of her baby. The pain was so difficult to manage that her hospital in rural Idaho transferred her to his medical center in Salt Lake City. She had also experienced respiratory arrest twice secondary to the application of fentanyl analgesic patches. “But she was relatively easy to manage once we tried a different drug, appropriately titrated,” he relates.

Dr. Bekanich spent two hours in the patient’s room adjusting the intravenous analgesic dose and monitoring the patient’s pulse oxygen level and neurological status. “These medicines don’t have to cause respiratory suppression, although it will happen occasionally, especially when there are multiple co-morbidities,” he says. “Hospitalists don’t realize that most of these problems can be avoided if you are meticulous in prescribing.”

Does Regulatory Scrutiny Chill Pain Treatment?

The ubiquitous fear of opioids and their potential side effects, including some unfounded or unrealistic fears, is also reflected in the regulation of controlled substances and physicians’ fears that they will be subjected to oppressive regulatory scrutiny.

Widely publicized cases of physicians being disciplined or prosecuted for over-prescribing opioids have only added to these fears, while the rare case of a physician being sued or sanctioned for under-prescribing pain medications does little to allay them.10

Growing attention to the inadequacies of and barriers to pain management—and the role of controlled substances regulation in those barriers—led to the 1998 promulgation of “Model Guidelines for the Use of Controlled Substances for the Treatment of Pain” by the Federation of State Medical Boards.11 These guidelines, promoting the legitimate role of opioids in relieving pain and acknowledging providers’ concerns about being disciplined, were revised in 2004 and have been adopted by 21 states.12

The effect remains, however. “For decades, physicians have reported being reluctant to prescribe opioids because of the fear of the stress, expense, and consequences of being investigated by licensing agencies or law enforcement,” states a 2006 state report card issued by the Pain & Policy Studies Group at the University of Wisconsin in Madison.13 “Some states—but far from all—have adopted policies which recognize that controlled substances are necessary for public health. … But in some states, pain treatment using opioids is unduly restricted by policies reflecting medical opinions that were discarded decades ago.”

The Pain & Policy Studies Group’s report card, which advocates for a balanced approach to the regulation and prescribing of controlled substances, has given every state a grade for how well it meets this goal. According to the 2006 report card, Michigan and Virginia get top grades for achieving balance in pain policy, while Georgia gets the lowest grade.

“Regulation is a real concern,” says Daniel Burkhardt, MD, associate professor and director of the Acute Pain Service at the University of California-San Francisco. “Every time a prosecutor arrests someone for prescribing too much pain medication, these things travel, adding to the extra regulatory burden on physicians.”

Carol Jessop, MD, a hospitalist and palliative care consultant at Alta Bates Summit Medical Center in Berkeley, Calif., says the burden has lessened somewhat in California because that state eliminated its requirements for triplicate paper prescribing forms for controlled substances.

A related concern involves the potential diversion of controlled substances by impaired healthcare professionals for personal use and abuse. This is another of the fears that have driven archaic pain regulation in many states. In fact, current estimates suggest that a substance abuse-related impairment will affect between 8% and 18% percent of physicians sometime in their lives, and that 2% of physicians are dealing with an active substance abuse problem.14

A recent medical journal letter to the editor from the Wisconsin Pain & Policy Studies Group suggests public policies on opioid diversion should focus more on sources of diversion such as “thefts, including armed robberies, night break-ins, and employee and customer pilferage,” rather than just the doctor-patient prescribing relationship.15

Physician diversion data don’t break out hospital medicine as a category, but some hospitalists say they have not heard of diversion problems involving hospitalist colleagues. That may reflect the fact that hospitalists, unlike some other health professionals, generally don’t administer controlled substances directly to the patient or have ready access to hospital drug storage facilities. TH

Larry Beresford is a regular contributor to The Hospitalist.

References

1. Joranson D, Payne R. Will my pain be managed? In Improving End-of-Life Care: The Role of Attorneys General. National Association of Attorneys General. Washington, D.C. 2003. Available at www.naag.org/end-of-life_healthcare.php. Last accessed April 13, 2007.
2. American Pain Society. Definitions related to the use of opioids for the treatment of pain: a consensus document from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine. Available at www.ampainsoc.org/advocacy/opioids2.htm. Last accessed April 13, 2007.
3. Weissman DE, Haddox JD. Opioid pseudoaddiction. Pain. 1989 Mar;36(3):363-366.
4. Weissman DE. Fast Fact and Concept #68: Is it pain or addiction? [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_68.htm. Last accessed April 13, 2007.
5. Weissman DE. Fast Fact and Concept #69: Pseudoaddiction. [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_69.htm. Last accessed April 13, 2007.
6. Doyle D, Hanks G, Cherny N, et al, eds. The Oxford Textbook of Palliative Medicine. 3rd ed. Oxford, England: Oxford University Press;2005:336.
7. Passik SD, Kirsh KL. Chapter 56: Pain in patients with alcohol and drug dependence. In Bruera E, Higginson I, von Gunten C, et al. Textbook of Palliative Medicine. London, England: Hodder Arnold;2006:517-524.
8. Von Gunten CF. Fast Fact and Concept #8: Morphine and hastened death. [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_008.htm. Last accessed April 13, 2007.
9. Portenoy RK, Siberceva U, Smout R, et al. Opioid use and survival at the end of life: a survey of a hospice population. J Pain Symptom Manage. 2006;32:532-540.
10. Warm EJ, Weissman DE. Fast Fact and Concept #63: The legal liability of under-treatment of pain. [The End of Life/Palliative Education Resource Center.] Available at: www.eperc.mcw.edu/fastFact/ff_63.htm. Last accessed April 13, 2007.
11. Federation of the State Medical Boards of the United States. Dallas, Texas. Available at www.fsmb.org. Accessed April 13, 2007.
12. National Association of Attorneys General. Improving End-of-Life Care: The Role of Attorneys General. National Association of Attorneys General. Washington, D.C. 2003. Available at www.naag.org/end-of-life_healthcare.php. Last accessed April 13, 2007.
13. Pain & Policy Studies Group. University of Wisconsin Paul P. Carbone Comprehensive Cancer Center. Available at: www.painpolicy.wisc.edu. Accessed April 13, 2007.
14. Blondell RD. Taking a proactive approach to physician impairment. Postgrad Med. 2005 Jul;118(1):16-18.
15. Joranson DE, Gilson AM. Drug crime is a source of abused pain medications in the United States. J Pain Symptom Manage. 2005 Oct;30(4):299-301.

Managing the pain of hospitalized patients is a fundamental ethical responsibility of hospitalists, enshrined as a core competency by SHM and, according to the Joint Commission on Healthcare Accreditation Organizations (JCAHO), a right for hospitalized patients.

Following last month’s exploration of IV pain medications (“Perfect Pain Control,” p. 40), this month we begin a three-part series on pain management issues in the hospital setting, based on interviews with working hospitalists and other pain experts.

Part one (below) provides a context for pain management and emphasizes assessment as the cornerstone of pain control. Next month, we will explore common dilemmas and difficult cases in pain management that can take hospitalists out of their comfort zone, along with the myths and realities of hot button topics such as addiction. The following month, we will chart the continuum of pain management modalities used in the hospital and discuss how working hospitalists can best utilize them for patients with special needs.

Listen to Your Patient’s Pain

Assessment and follow-up remain key to managing hospitalized patients’ pain. Stephen J. Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and consultant on the medical center’s palliative care service, remembers a hospitalized patient whose pain problem was not what it seemed—although a more careful assessment showed the way to a solution. A woman in her early 80s who resided in a long-term-care facility was admitted to the hospital with out-of-control back pain and mild dementia. House staff fitted her with a patient-controlled analgesia (PCA) pump to treat her pain, with instructions to press the control button whenever she experienced pain. Dr. Bekanich got a call 48 hours later because the patient was still voicing significant pain complaints, despite the PCA.

“I found that her pain scores were taken by the nurses every four hours, which is not often enough when pain is out of control,” he says. “I also looked at a printout of the PCA history, which indicated that she had only pressed the button 10 or 12 times in 48 hours. You would have expected a lot more attempts, given her reports of pain.”

Dr. Bekanich showed the patient the PCA button and asked her, “ ‘What’s this?’ She replied, ‘I can’t see it. I don’t have my glasses here in the hospital.’ When I put it in her hand, she said, ‘This is what I use to call the nurse.’ ”

A small tag on the PCA handle indicated that the patient should push for pain, but the patient was unable to read it. Once Dr. Bekanich understood her functional limitations, he wrote a new order for continuous infusion of an opioid analgesic, which brought the pain under control.

This case illustrates several principles of effective pain management. First is the importance of assessing the various factors that influence pain and the physician’s need to look more deeply if the pain doesn’t respond to initial measures. “That should be a warning flag to ask, ‘OK, what am I missing?’ ” Also, for moderate to severe pain, a component of around-the-clock dosing or continuous infusion to bring the pain under control is just as important as having the availability of a PRN analgesic for responding to breakthrough pain, such as starting the patient on a PCA.

Pain: The Hospitalist’s Responsibility

According to Health, United States, 2006, the federal government’s annual, comprehensive report on America’s health, issued last November by the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, one-quarter of U.S. adults say they suffered a bout of pain lasting 24 hours or more in the past month. One in 10 says the pain lasted a year or more.

The CDC chose to focus on pain in the latest annual report “because it is rarely discussed as a condition in and of itself; it is mostly viewed as a byproduct of another condition,” says lead study author Amy Bernstein, who also cites the medical costs of pain and pain disparities among different population groups. Other studies have identified physicians’ self-reported discomfort with their training in pain management and with their ability to manage their patients’ pain.

Pain is also the reason many patients end up in the hospital, and treating pain should be the expectation of every hospitalist, says Robert V. Brody, MD, chief of the pain service at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. Effective pain management begins with the pain assessment, but equally important is the follow-up to reassess how the pain responds to initial measures, Dr. Brody says. If initial approaches fail to manage the pain, try again with a new dose, drug, or combination. Then reassess and repeat as often as necessary—viewing the pain challenge as a puzzle to be solved.

Pain is defined by the International Association for the Study of Pain as “an unpleasant experience associated with actual or potential tissue damage to a person’s body.” Key to that definition, notes Dr. Brody, is the recognition that pain is ultimately a subjective phenomenon, reflecting the patient’s perception of and emotional reaction to the unpleasant sensation. Patients are thus the best source of information on how much pain they are experiencing.

In recent years, standardized pain scales (typically ranging from zero—no pain, to 10—the worst pain imaginable) have gained currency in U.S. hospitals and other healthcare settings, thanks to the growing emphasis on pain management by groups such as the Joint Commission. (See “Pain Assessment Scales,” p. 49.) Such pain scales make it possible to quantify, chart, and track over time the patient’s subjective, self-reported pain scores. But while nurses may be regularly charting patients’ pain scores, hospitalists need to review those scores.

“We used to say that treating pain is not rocket science, but clearly there are skills and knowledge that hospitalists should acquire, including how to handle difficult issues around substance abuse or mental health,” explains Dr. Brody. “Certain basic rules of pain management can go a long way if you’re open to the belief that learning those rules is important and if you have an expectation that you will bring the patient’s pain under control.

“Talk to the patient,” he advises. “Ask what are the patient’s goals for pain relief.” The goal is not necessarily zero pain but a balance between pain relief and side effects from analgesics, based on functional status, defined goals, and the patient’s expressed preferences.

With practice, hospitalists can gain comfort with prescribing short-acting and long-acting opioids plus adjuvant treatments sufficient to address the majority of pain cases. They can also learn to convert between oral and intravenous opioid administration. But they must recognize when to call for reinforcements, such as the hospital’s pain service or a palliative care consultant, for assistance with more challenging cases. Ultimately, effective pain management in the hospital is multi-disciplinary, drawing at different times on the complementary perspectives of other team members, including the nurse, pharmacist, social worker, and chaplain.

“The first step to improving pain management is to develop awareness of the problem,” says Steven Pantilat, MD, a hospitalist, associate professor of clinical medicine, Department of Medicine, University of California, San Francisco, and past president of SHM. “But you also have to be comfortable giving adequate doses of these medications. You get comfortable through experience.”

Dr. Pantilat recommends that hospitalists stick with a few familiar opioids, both short-acting and long-acting. “But 90% of pain can be managed by a hospitalist without need for consultation.” He is also the past-president of SHM and the Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care at UCSF.

Start with the Assessment

Pain assessment identifies the location, cause, intensity, duration, and nature of the pain, recognizing that many chronically ill patients may have more than one source of pain. It is important to establish why the patient is in pain because different pain responds to different treatments. It may also be helpful to know how long the patient has experienced the pain, how it was treated prior to the hospitalization, how it responded to treatment in the past, what makes the pain better or worse, and how it affects sleep, appetite, or physical activity.

Have the patient describe what the pain is like—the quality of the pain—using his or her own words, suggests Carol Jessop, MD, a hospitalist and palliative care physician at Alta Bates Summit Medical Center in Berkeley, Calif. There may also be psychological or spiritual elements of the pain—other sources that are not physical but contribute to a pain experience that is very real to the patient. A thorough pain assessment also evaluates the patient’s psychological state, including depression and anxiety, as well as past history of alcohol or drug use. It covers the patient’s and the patient’s family’s attitudes toward the use of opioid analgesics, their cultural context, and the meaning that the patient ascribes to his or her pain.

It can take a long time to gather all of that information as part of a comprehensive pain history, however—time that busy hospitalists may not be able to spare, says Dr. Bekanich. Fortunately, not every hospitalized patient requires this level of detail. But if there is reason to expect complications or difficulties in bringing the pain under control, if the pain doesn’t respond to standard analgesic treatments, or if there are reasons for avoiding opioid analgesics, then it may be worth making the time—or recruiting someone who can take a detailed pain history that would provide a baseline for future assessments.

“The most important thing to remember is that pain is what the patient says it is,” says Dr. Pantilat. “We are challenged by wondering whether the patient is really in pain. The answer has to be yes. You have to trust the patient unless you have specific reasons not to.

“It seems to me the first assessment of the patient’s pain may need to be more complex: Is there something new going on with this patient?” he continues. “If someone comes into the hospital with a new fracture or a kidney stone, you don’t need to spend as much time figuring out the pain’s source. But if it is chronic pain that has been unmanaged for a significant amount of time, that’s when you sit down and say, ‘OK, tell me about your pain.’ There’s no one size fits all in pain assessment.”

Other Issues

A special focus in pain assessment is recognizing neuropathic pain—resulting from injury or damage to the nerves themselves, which is different in nature and treatment from nociceptive pain and is also generally less responsive to opiate analgesics. Roughly 15% of the pain hospitalists see may be neuropathic, which can be suggested by certain words, such as burning, numbing, tingling, or shooting, in the patient’s description of the pain. Certain syndromes also suggest the possibility of neuropathic pain, including diabetes, HIV, alcoholism, radiation or chemotherapy, and amputation and phantom limb pain. Neuropathic pain may be treated with tricyclic antidepressants such as desipramine (Norpramin, Petrofrane) and nortriptyline (Pamelor, Aventyl) as well as with the anticonvulsant gabapentin.1,2

Another key issue in pain management involves side effects. With opioids, constipation is such a common side effect that experts recommend prescribing a laxative and/or stool softener every time an opioid analgesic is initiated. The physician must then stay on top of the issue, prescribing additional laxatives if the desired effect is not achieved. Other side effects of opioids, which must be balanced with their analgesic properties, include nausea, sedation, mental status changes, and respiratory suppression. A number of these side effects will dissipate after a few days on opioids, but constipation remains problematic.

Other basic principles of pain management, gathered from physicians interviewed for this article and from other pain resources (see “Resources and Tools,” p. 49) include:

• There is no absolute maximum dose of opioids; adjust dose based on individual need and response. If initial doses are not effective, titrate up based on percentages of the dose: 25%-50% for mild to moderate pain, 50%-100% for moderate to severe pain.
• Use the right duration in prescribing; short-acting opioids may be more effective when given every four hours than every six hours. PRN prescriptions are not recommended except for breakthrough pain. The World Health Organization’s Pain Ladder suggests an overall approach to dosing based on severity.
• Tailor the pain regimen while the patient is still in front of you, if possible. The patient’s response to intravenous analgesics should start to become clear within 10 minutes of initiation.
• The earlier you treat pain, the easier it will be to bring it under control.
• Oral administration is generally preferable to intravenous unless there is a reason to avoid using the oral route.
• Pain experts do not generally recommend meperidine as an analgesic.3
• Opioids are not recommended for all kinds of pain. Opioids may be avoided for patients with neuropathic pain, for those with existing constipation or nausea problems, or for morbidly obese patients with bad sleep apnea.

Finally, work with primary care physicians to plan for pain needs post-discharge, as well as for potential problems or barriers that may arise, especially if high doses of opioids are involved.

“One of the most difficult issues is addressing what will happen after the patient leaves the hospital,” says Dr. Bekanich. “That’s where the ball often gets dropped.”

He makes a point of calling the patient’s primary physician at the time of discharge and then dictates a letter, including the pain protocol, which is transcribed and faxed to the primary physician. “We don’t let these patients walk out the door without an appointment date already scheduled with a physician,” he says.

Benefits of Pain Relief

Dr. Jessop encourages hospitalists to take advantage of SHM’s core competency in pain management as a guide to improving their skills in this area. Managing patients’ pain is a win/win for the physician, the patient, and the institution. “Nothing feels better than getting a patient out of pain,” she says.

Better outcomes in pain management can help bring down hospital lengths of stay while driving up patient and staff satisfaction, adds Dr. Bekanich. Conversely, unrelieved pain not only leads to unnecessary suffering but also to patients who are depressed, slower to get up and start walking or eating, and reluctant to take deep breaths. “It’s hard to discharge a hospitalized patient whose pain is still out of control,” he says.

Dr. Bekanich reports that his own interest in learning pain management techniques resulted from watching his grandmother experience severe pain while struggling with cancer. “That was the driving force for me to say, ‘We can do so much better at this,’ and then get the training I needed,” he says.

Dr. Bekanich attended conferences offered by the Center to Advance Palliative Care and the American Academy of Hospice and Palliative Medicine. “I started to read a lot more in the pain literature,” he explains. “Initially, I was somewhat self-conscious about putting the new techniques into effect. So I’d call a pharmacist or a mentor to double check. I’m glad I did that.” TH

Larry Beresford is a regular contributor to The Hospitalist.

References

1. Smith TE, Chong MS. Neuropathic pain. Hosp Med. 2000;61(11):760-766.
2. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain (review). Cochrane Database Syst Rev. 2005 Jul 20;(3)3:CD005454.
3. Weissman DE. Fast Fact and Concept #71: Meperidine for pain—what’s all the fuss? [The End of Life/Palliative Education Resource Center.] Available at: www.eperc.mcw.edu/fastFact/ff_71.htm. Last accessed February 19, 2007.

Managing the pain of hospitalized patients is a fundamental ethical responsibility of hospitalists, enshrined as a core competency by SHM and, according to the Joint Commission on Healthcare Accreditation Organizations (JCAHO), a right for hospitalized patients.

Following last month’s exploration of IV pain medications (“Perfect Pain Control,” p. 40), this month we begin a three-part series on pain management issues in the hospital setting, based on interviews with working hospitalists and other pain experts.

Part one (below) provides a context for pain management and emphasizes assessment as the cornerstone of pain control. Next month, we will explore common dilemmas and difficult cases in pain management that can take hospitalists out of their comfort zone, along with the myths and realities of hot button topics such as addiction. The following month, we will chart the continuum of pain management modalities used in the hospital and discuss how working hospitalists can best utilize them for patients with special needs.

Listen to Your Patient’s Pain

Assessment and follow-up remain key to managing hospitalized patients’ pain. Stephen J. Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and consultant on the medical center’s palliative care service, remembers a hospitalized patient whose pain problem was not what it seemed—although a more careful assessment showed the way to a solution. A woman in her early 80s who resided in a long-term-care facility was admitted to the hospital with out-of-control back pain and mild dementia. House staff fitted her with a patient-controlled analgesia (PCA) pump to treat her pain, with instructions to press the control button whenever she experienced pain. Dr. Bekanich got a call 48 hours later because the patient was still voicing significant pain complaints, despite the PCA.

“I found that her pain scores were taken by the nurses every four hours, which is not often enough when pain is out of control,” he says. “I also looked at a printout of the PCA history, which indicated that she had only pressed the button 10 or 12 times in 48 hours. You would have expected a lot more attempts, given her reports of pain.”

Dr. Bekanich showed the patient the PCA button and asked her, “ ‘What’s this?’ She replied, ‘I can’t see it. I don’t have my glasses here in the hospital.’ When I put it in her hand, she said, ‘This is what I use to call the nurse.’ ”

A small tag on the PCA handle indicated that the patient should push for pain, but the patient was unable to read it. Once Dr. Bekanich understood her functional limitations, he wrote a new order for continuous infusion of an opioid analgesic, which brought the pain under control.

This case illustrates several principles of effective pain management. First is the importance of assessing the various factors that influence pain and the physician’s need to look more deeply if the pain doesn’t respond to initial measures. “That should be a warning flag to ask, ‘OK, what am I missing?’ ” Also, for moderate to severe pain, a component of around-the-clock dosing or continuous infusion to bring the pain under control is just as important as having the availability of a PRN analgesic for responding to breakthrough pain, such as starting the patient on a PCA.

Pain: The Hospitalist’s Responsibility

According to Health, United States, 2006, the federal government’s annual, comprehensive report on America’s health, issued last November by the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, one-quarter of U.S. adults say they suffered a bout of pain lasting 24 hours or more in the past month. One in 10 says the pain lasted a year or more.

The CDC chose to focus on pain in the latest annual report “because it is rarely discussed as a condition in and of itself; it is mostly viewed as a byproduct of another condition,” says lead study author Amy Bernstein, who also cites the medical costs of pain and pain disparities among different population groups. Other studies have identified physicians’ self-reported discomfort with their training in pain management and with their ability to manage their patients’ pain.

Pain is also the reason many patients end up in the hospital, and treating pain should be the expectation of every hospitalist, says Robert V. Brody, MD, chief of the pain service at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. Effective pain management begins with the pain assessment, but equally important is the follow-up to reassess how the pain responds to initial measures, Dr. Brody says. If initial approaches fail to manage the pain, try again with a new dose, drug, or combination. Then reassess and repeat as often as necessary—viewing the pain challenge as a puzzle to be solved.

Pain is defined by the International Association for the Study of Pain as “an unpleasant experience associated with actual or potential tissue damage to a person’s body.” Key to that definition, notes Dr. Brody, is the recognition that pain is ultimately a subjective phenomenon, reflecting the patient’s perception of and emotional reaction to the unpleasant sensation. Patients are thus the best source of information on how much pain they are experiencing.

In recent years, standardized pain scales (typically ranging from zero—no pain, to 10—the worst pain imaginable) have gained currency in U.S. hospitals and other healthcare settings, thanks to the growing emphasis on pain management by groups such as the Joint Commission. (See “Pain Assessment Scales,” p. 49.) Such pain scales make it possible to quantify, chart, and track over time the patient’s subjective, self-reported pain scores. But while nurses may be regularly charting patients’ pain scores, hospitalists need to review those scores.

“We used to say that treating pain is not rocket science, but clearly there are skills and knowledge that hospitalists should acquire, including how to handle difficult issues around substance abuse or mental health,” explains Dr. Brody. “Certain basic rules of pain management can go a long way if you’re open to the belief that learning those rules is important and if you have an expectation that you will bring the patient’s pain under control.

“Talk to the patient,” he advises. “Ask what are the patient’s goals for pain relief.” The goal is not necessarily zero pain but a balance between pain relief and side effects from analgesics, based on functional status, defined goals, and the patient’s expressed preferences.

With practice, hospitalists can gain comfort with prescribing short-acting and long-acting opioids plus adjuvant treatments sufficient to address the majority of pain cases. They can also learn to convert between oral and intravenous opioid administration. But they must recognize when to call for reinforcements, such as the hospital’s pain service or a palliative care consultant, for assistance with more challenging cases. Ultimately, effective pain management in the hospital is multi-disciplinary, drawing at different times on the complementary perspectives of other team members, including the nurse, pharmacist, social worker, and chaplain.

“The first step to improving pain management is to develop awareness of the problem,” says Steven Pantilat, MD, a hospitalist, associate professor of clinical medicine, Department of Medicine, University of California, San Francisco, and past president of SHM. “But you also have to be comfortable giving adequate doses of these medications. You get comfortable through experience.”

Dr. Pantilat recommends that hospitalists stick with a few familiar opioids, both short-acting and long-acting. “But 90% of pain can be managed by a hospitalist without need for consultation.” He is also the past-president of SHM and the Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care at UCSF.

Start with the Assessment

Pain assessment identifies the location, cause, intensity, duration, and nature of the pain, recognizing that many chronically ill patients may have more than one source of pain. It is important to establish why the patient is in pain because different pain responds to different treatments. It may also be helpful to know how long the patient has experienced the pain, how it was treated prior to the hospitalization, how it responded to treatment in the past, what makes the pain better or worse, and how it affects sleep, appetite, or physical activity.

Have the patient describe what the pain is like—the quality of the pain—using his or her own words, suggests Carol Jessop, MD, a hospitalist and palliative care physician at Alta Bates Summit Medical Center in Berkeley, Calif. There may also be psychological or spiritual elements of the pain—other sources that are not physical but contribute to a pain experience that is very real to the patient. A thorough pain assessment also evaluates the patient’s psychological state, including depression and anxiety, as well as past history of alcohol or drug use. It covers the patient’s and the patient’s family’s attitudes toward the use of opioid analgesics, their cultural context, and the meaning that the patient ascribes to his or her pain.

It can take a long time to gather all of that information as part of a comprehensive pain history, however—time that busy hospitalists may not be able to spare, says Dr. Bekanich. Fortunately, not every hospitalized patient requires this level of detail. But if there is reason to expect complications or difficulties in bringing the pain under control, if the pain doesn’t respond to standard analgesic treatments, or if there are reasons for avoiding opioid analgesics, then it may be worth making the time—or recruiting someone who can take a detailed pain history that would provide a baseline for future assessments.

“The most important thing to remember is that pain is what the patient says it is,” says Dr. Pantilat. “We are challenged by wondering whether the patient is really in pain. The answer has to be yes. You have to trust the patient unless you have specific reasons not to.

“It seems to me the first assessment of the patient’s pain may need to be more complex: Is there something new going on with this patient?” he continues. “If someone comes into the hospital with a new fracture or a kidney stone, you don’t need to spend as much time figuring out the pain’s source. But if it is chronic pain that has been unmanaged for a significant amount of time, that’s when you sit down and say, ‘OK, tell me about your pain.’ There’s no one size fits all in pain assessment.”

Other Issues

A special focus in pain assessment is recognizing neuropathic pain—resulting from injury or damage to the nerves themselves, which is different in nature and treatment from nociceptive pain and is also generally less responsive to opiate analgesics. Roughly 15% of the pain hospitalists see may be neuropathic, which can be suggested by certain words, such as burning, numbing, tingling, or shooting, in the patient’s description of the pain. Certain syndromes also suggest the possibility of neuropathic pain, including diabetes, HIV, alcoholism, radiation or chemotherapy, and amputation and phantom limb pain. Neuropathic pain may be treated with tricyclic antidepressants such as desipramine (Norpramin, Petrofrane) and nortriptyline (Pamelor, Aventyl) as well as with the anticonvulsant gabapentin.1,2

Another key issue in pain management involves side effects. With opioids, constipation is such a common side effect that experts recommend prescribing a laxative and/or stool softener every time an opioid analgesic is initiated. The physician must then stay on top of the issue, prescribing additional laxatives if the desired effect is not achieved. Other side effects of opioids, which must be balanced with their analgesic properties, include nausea, sedation, mental status changes, and respiratory suppression. A number of these side effects will dissipate after a few days on opioids, but constipation remains problematic.

Other basic principles of pain management, gathered from physicians interviewed for this article and from other pain resources (see “Resources and Tools,” p. 49) include:

• There is no absolute maximum dose of opioids; adjust dose based on individual need and response. If initial doses are not effective, titrate up based on percentages of the dose: 25%-50% for mild to moderate pain, 50%-100% for moderate to severe pain.
• Use the right duration in prescribing; short-acting opioids may be more effective when given every four hours than every six hours. PRN prescriptions are not recommended except for breakthrough pain. The World Health Organization’s Pain Ladder suggests an overall approach to dosing based on severity.
• Tailor the pain regimen while the patient is still in front of you, if possible. The patient’s response to intravenous analgesics should start to become clear within 10 minutes of initiation.
• The earlier you treat pain, the easier it will be to bring it under control.
• Oral administration is generally preferable to intravenous unless there is a reason to avoid using the oral route.
• Pain experts do not generally recommend meperidine as an analgesic.3
• Opioids are not recommended for all kinds of pain. Opioids may be avoided for patients with neuropathic pain, for those with existing constipation or nausea problems, or for morbidly obese patients with bad sleep apnea.

Finally, work with primary care physicians to plan for pain needs post-discharge, as well as for potential problems or barriers that may arise, especially if high doses of opioids are involved.

“One of the most difficult issues is addressing what will happen after the patient leaves the hospital,” says Dr. Bekanich. “That’s where the ball often gets dropped.”

He makes a point of calling the patient’s primary physician at the time of discharge and then dictates a letter, including the pain protocol, which is transcribed and faxed to the primary physician. “We don’t let these patients walk out the door without an appointment date already scheduled with a physician,” he says.

Benefits of Pain Relief

Dr. Jessop encourages hospitalists to take advantage of SHM’s core competency in pain management as a guide to improving their skills in this area. Managing patients’ pain is a win/win for the physician, the patient, and the institution. “Nothing feels better than getting a patient out of pain,” she says.

Better outcomes in pain management can help bring down hospital lengths of stay while driving up patient and staff satisfaction, adds Dr. Bekanich. Conversely, unrelieved pain not only leads to unnecessary suffering but also to patients who are depressed, slower to get up and start walking or eating, and reluctant to take deep breaths. “It’s hard to discharge a hospitalized patient whose pain is still out of control,” he says.

Dr. Bekanich reports that his own interest in learning pain management techniques resulted from watching his grandmother experience severe pain while struggling with cancer. “That was the driving force for me to say, ‘We can do so much better at this,’ and then get the training I needed,” he says.

Dr. Bekanich attended conferences offered by the Center to Advance Palliative Care and the American Academy of Hospice and Palliative Medicine. “I started to read a lot more in the pain literature,” he explains. “Initially, I was somewhat self-conscious about putting the new techniques into effect. So I’d call a pharmacist or a mentor to double check. I’m glad I did that.” TH

Larry Beresford is a regular contributor to The Hospitalist.

References

1. Smith TE, Chong MS. Neuropathic pain. Hosp Med. 2000;61(11):760-766.
2. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain (review). Cochrane Database Syst Rev. 2005 Jul 20;(3)3:CD005454.
3. Weissman DE. Fast Fact and Concept #71: Meperidine for pain—what’s all the fuss? [The End of Life/Palliative Education Resource Center.] Available at: www.eperc.mcw.edu/fastFact/ff_71.htm. Last accessed February 19, 2007.

Managing the pain of hospitalized patients is a fundamental ethical responsibility of hospitalists, enshrined as a core competency by SHM and, according to the Joint Commission on Healthcare Accreditation Organizations (JCAHO), a right for hospitalized patients.

Following last month’s exploration of IV pain medications (“Perfect Pain Control,” p. 40), this month we begin a three-part series on pain management issues in the hospital setting, based on interviews with working hospitalists and other pain experts.

Part one (below) provides a context for pain management and emphasizes assessment as the cornerstone of pain control. Next month, we will explore common dilemmas and difficult cases in pain management that can take hospitalists out of their comfort zone, along with the myths and realities of hot button topics such as addiction. The following month, we will chart the continuum of pain management modalities used in the hospital and discuss how working hospitalists can best utilize them for patients with special needs.

Listen to Your Patient’s Pain

Assessment and follow-up remain key to managing hospitalized patients’ pain. Stephen J. Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and consultant on the medical center’s palliative care service, remembers a hospitalized patient whose pain problem was not what it seemed—although a more careful assessment showed the way to a solution. A woman in her early 80s who resided in a long-term-care facility was admitted to the hospital with out-of-control back pain and mild dementia. House staff fitted her with a patient-controlled analgesia (PCA) pump to treat her pain, with instructions to press the control button whenever she experienced pain. Dr. Bekanich got a call 48 hours later because the patient was still voicing significant pain complaints, despite the PCA.

“I found that her pain scores were taken by the nurses every four hours, which is not often enough when pain is out of control,” he says. “I also looked at a printout of the PCA history, which indicated that she had only pressed the button 10 or 12 times in 48 hours. You would have expected a lot more attempts, given her reports of pain.”

Dr. Bekanich showed the patient the PCA button and asked her, “ ‘What’s this?’ She replied, ‘I can’t see it. I don’t have my glasses here in the hospital.’ When I put it in her hand, she said, ‘This is what I use to call the nurse.’ ”

A small tag on the PCA handle indicated that the patient should push for pain, but the patient was unable to read it. Once Dr. Bekanich understood her functional limitations, he wrote a new order for continuous infusion of an opioid analgesic, which brought the pain under control.

This case illustrates several principles of effective pain management. First is the importance of assessing the various factors that influence pain and the physician’s need to look more deeply if the pain doesn’t respond to initial measures. “That should be a warning flag to ask, ‘OK, what am I missing?’ ” Also, for moderate to severe pain, a component of around-the-clock dosing or continuous infusion to bring the pain under control is just as important as having the availability of a PRN analgesic for responding to breakthrough pain, such as starting the patient on a PCA.

Pain: The Hospitalist’s Responsibility

According to Health, United States, 2006, the federal government’s annual, comprehensive report on America’s health, issued last November by the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, one-quarter of U.S. adults say they suffered a bout of pain lasting 24 hours or more in the past month. One in 10 says the pain lasted a year or more.

The CDC chose to focus on pain in the latest annual report “because it is rarely discussed as a condition in and of itself; it is mostly viewed as a byproduct of another condition,” says lead study author Amy Bernstein, who also cites the medical costs of pain and pain disparities among different population groups. Other studies have identified physicians’ self-reported discomfort with their training in pain management and with their ability to manage their patients’ pain.

Pain is also the reason many patients end up in the hospital, and treating pain should be the expectation of every hospitalist, says Robert V. Brody, MD, chief of the pain service at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. Effective pain management begins with the pain assessment, but equally important is the follow-up to reassess how the pain responds to initial measures, Dr. Brody says. If initial approaches fail to manage the pain, try again with a new dose, drug, or combination. Then reassess and repeat as often as necessary—viewing the pain challenge as a puzzle to be solved.

Pain is defined by the International Association for the Study of Pain as “an unpleasant experience associated with actual or potential tissue damage to a person’s body.” Key to that definition, notes Dr. Brody, is the recognition that pain is ultimately a subjective phenomenon, reflecting the patient’s perception of and emotional reaction to the unpleasant sensation. Patients are thus the best source of information on how much pain they are experiencing.

In recent years, standardized pain scales (typically ranging from zero—no pain, to 10—the worst pain imaginable) have gained currency in U.S. hospitals and other healthcare settings, thanks to the growing emphasis on pain management by groups such as the Joint Commission. (See “Pain Assessment Scales,” p. 49.) Such pain scales make it possible to quantify, chart, and track over time the patient’s subjective, self-reported pain scores. But while nurses may be regularly charting patients’ pain scores, hospitalists need to review those scores.

“We used to say that treating pain is not rocket science, but clearly there are skills and knowledge that hospitalists should acquire, including how to handle difficult issues around substance abuse or mental health,” explains Dr. Brody. “Certain basic rules of pain management can go a long way if you’re open to the belief that learning those rules is important and if you have an expectation that you will bring the patient’s pain under control.

“Talk to the patient,” he advises. “Ask what are the patient’s goals for pain relief.” The goal is not necessarily zero pain but a balance between pain relief and side effects from analgesics, based on functional status, defined goals, and the patient’s expressed preferences.

With practice, hospitalists can gain comfort with prescribing short-acting and long-acting opioids plus adjuvant treatments sufficient to address the majority of pain cases. They can also learn to convert between oral and intravenous opioid administration. But they must recognize when to call for reinforcements, such as the hospital’s pain service or a palliative care consultant, for assistance with more challenging cases. Ultimately, effective pain management in the hospital is multi-disciplinary, drawing at different times on the complementary perspectives of other team members, including the nurse, pharmacist, social worker, and chaplain.

“The first step to improving pain management is to develop awareness of the problem,” says Steven Pantilat, MD, a hospitalist, associate professor of clinical medicine, Department of Medicine, University of California, San Francisco, and past president of SHM. “But you also have to be comfortable giving adequate doses of these medications. You get comfortable through experience.”

Dr. Pantilat recommends that hospitalists stick with a few familiar opioids, both short-acting and long-acting. “But 90% of pain can be managed by a hospitalist without need for consultation.” He is also the past-president of SHM and the Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care at UCSF.

Start with the Assessment

Pain assessment identifies the location, cause, intensity, duration, and nature of the pain, recognizing that many chronically ill patients may have more than one source of pain. It is important to establish why the patient is in pain because different pain responds to different treatments. It may also be helpful to know how long the patient has experienced the pain, how it was treated prior to the hospitalization, how it responded to treatment in the past, what makes the pain better or worse, and how it affects sleep, appetite, or physical activity.

Have the patient describe what the pain is like—the quality of the pain—using his or her own words, suggests Carol Jessop, MD, a hospitalist and palliative care physician at Alta Bates Summit Medical Center in Berkeley, Calif. There may also be psychological or spiritual elements of the pain—other sources that are not physical but contribute to a pain experience that is very real to the patient. A thorough pain assessment also evaluates the patient’s psychological state, including depression and anxiety, as well as past history of alcohol or drug use. It covers the patient’s and the patient’s family’s attitudes toward the use of opioid analgesics, their cultural context, and the meaning that the patient ascribes to his or her pain.

It can take a long time to gather all of that information as part of a comprehensive pain history, however—time that busy hospitalists may not be able to spare, says Dr. Bekanich. Fortunately, not every hospitalized patient requires this level of detail. But if there is reason to expect complications or difficulties in bringing the pain under control, if the pain doesn’t respond to standard analgesic treatments, or if there are reasons for avoiding opioid analgesics, then it may be worth making the time—or recruiting someone who can take a detailed pain history that would provide a baseline for future assessments.

“The most important thing to remember is that pain is what the patient says it is,” says Dr. Pantilat. “We are challenged by wondering whether the patient is really in pain. The answer has to be yes. You have to trust the patient unless you have specific reasons not to.

“It seems to me the first assessment of the patient’s pain may need to be more complex: Is there something new going on with this patient?” he continues. “If someone comes into the hospital with a new fracture or a kidney stone, you don’t need to spend as much time figuring out the pain’s source. But if it is chronic pain that has been unmanaged for a significant amount of time, that’s when you sit down and say, ‘OK, tell me about your pain.’ There’s no one size fits all in pain assessment.”

Other Issues

A special focus in pain assessment is recognizing neuropathic pain—resulting from injury or damage to the nerves themselves, which is different in nature and treatment from nociceptive pain and is also generally less responsive to opiate analgesics. Roughly 15% of the pain hospitalists see may be neuropathic, which can be suggested by certain words, such as burning, numbing, tingling, or shooting, in the patient’s description of the pain. Certain syndromes also suggest the possibility of neuropathic pain, including diabetes, HIV, alcoholism, radiation or chemotherapy, and amputation and phantom limb pain. Neuropathic pain may be treated with tricyclic antidepressants such as desipramine (Norpramin, Petrofrane) and nortriptyline (Pamelor, Aventyl) as well as with the anticonvulsant gabapentin.1,2

Another key issue in pain management involves side effects. With opioids, constipation is such a common side effect that experts recommend prescribing a laxative and/or stool softener every time an opioid analgesic is initiated. The physician must then stay on top of the issue, prescribing additional laxatives if the desired effect is not achieved. Other side effects of opioids, which must be balanced with their analgesic properties, include nausea, sedation, mental status changes, and respiratory suppression. A number of these side effects will dissipate after a few days on opioids, but constipation remains problematic.

Other basic principles of pain management, gathered from physicians interviewed for this article and from other pain resources (see “Resources and Tools,” p. 49) include:

• There is no absolute maximum dose of opioids; adjust dose based on individual need and response. If initial doses are not effective, titrate up based on percentages of the dose: 25%-50% for mild to moderate pain, 50%-100% for moderate to severe pain.
• Use the right duration in prescribing; short-acting opioids may be more effective when given every four hours than every six hours. PRN prescriptions are not recommended except for breakthrough pain. The World Health Organization’s Pain Ladder suggests an overall approach to dosing based on severity.
• Tailor the pain regimen while the patient is still in front of you, if possible. The patient’s response to intravenous analgesics should start to become clear within 10 minutes of initiation.
• The earlier you treat pain, the easier it will be to bring it under control.
• Oral administration is generally preferable to intravenous unless there is a reason to avoid using the oral route.
• Pain experts do not generally recommend meperidine as an analgesic.3
• Opioids are not recommended for all kinds of pain. Opioids may be avoided for patients with neuropathic pain, for those with existing constipation or nausea problems, or for morbidly obese patients with bad sleep apnea.

Finally, work with primary care physicians to plan for pain needs post-discharge, as well as for potential problems or barriers that may arise, especially if high doses of opioids are involved.

“One of the most difficult issues is addressing what will happen after the patient leaves the hospital,” says Dr. Bekanich. “That’s where the ball often gets dropped.”

He makes a point of calling the patient’s primary physician at the time of discharge and then dictates a letter, including the pain protocol, which is transcribed and faxed to the primary physician. “We don’t let these patients walk out the door without an appointment date already scheduled with a physician,” he says.

Benefits of Pain Relief

Dr. Jessop encourages hospitalists to take advantage of SHM’s core competency in pain management as a guide to improving their skills in this area. Managing patients’ pain is a win/win for the physician, the patient, and the institution. “Nothing feels better than getting a patient out of pain,” she says.

Better outcomes in pain management can help bring down hospital lengths of stay while driving up patient and staff satisfaction, adds Dr. Bekanich. Conversely, unrelieved pain not only leads to unnecessary suffering but also to patients who are depressed, slower to get up and start walking or eating, and reluctant to take deep breaths. “It’s hard to discharge a hospitalized patient whose pain is still out of control,” he says.

Dr. Bekanich reports that his own interest in learning pain management techniques resulted from watching his grandmother experience severe pain while struggling with cancer. “That was the driving force for me to say, ‘We can do so much better at this,’ and then get the training I needed,” he says.

Dr. Bekanich attended conferences offered by the Center to Advance Palliative Care and the American Academy of Hospice and Palliative Medicine. “I started to read a lot more in the pain literature,” he explains. “Initially, I was somewhat self-conscious about putting the new techniques into effect. So I’d call a pharmacist or a mentor to double check. I’m glad I did that.” TH

Larry Beresford is a regular contributor to The Hospitalist.

References

1. Smith TE, Chong MS. Neuropathic pain. Hosp Med. 2000;61(11):760-766.
2. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain (review). Cochrane Database Syst Rev. 2005 Jul 20;(3)3:CD005454.
3. Weissman DE. Fast Fact and Concept #71: Meperidine for pain—what’s all the fuss? [The End of Life/Palliative Education Resource Center.] Available at: www.eperc.mcw.edu/fastFact/ff_71.htm. Last accessed February 19, 2007.

In March 2005, the Association of American Medical Colleges announced that America will face a shortage of between 85,000 and 200,000 physicians by 2020. The U.S. population is growing faster than the number of new physicians entering the workforce. How big the shortfall will be has been argued since last year, but most pundits expect there to be too few physicians—in total—to take care of the burgeoning population, especially the elderly.

If a shortage of physicians is to be anticipated, what effect might this have on hospitals and hospitalists?

Where Does the Number Come From?

The debate about the range of the projected shortfall of 85,000 to 200,000 physicians reflects several differing assumptions. All estimates are based on the ratio of physicians to the overall population. Different estimates are based on distinctive models for the necessary staffing of the medical enterprise. For example, prepaid medical groups that serve large populations of patients (e.g., Kaiser Permanente) have physician-per-capita ratios of up to 20% less than fee-for-service environments. A larger elderly population will likely demand more medical services per capita. So, the estimate of a shortfall depends on the model of medical care for 2020 anticipated to be predominant in 2020 and a calculation of usage rate per capita for services—again, especially among the elderly.

Work/life balance choices that recent medical school graduates make also add to the uncertainty of predictions concerning the relative size of the shortage in total and by specialty. Young men and women graduating today increasingly express a preference for reduced or more manageable hours of work per week, sometimes opting for shift work or other forms of more predictable workload. There is also an understanding that women physicians tend to work part-time in some stages of their career—especially when they are trying to balance the demands of starting and raising a young family. Many of their male spouses are making similar choices.

The Specialty Nature of the Shortfall

A relative shortfall in available physicians relates to the specialty choice of new residency graduates. From 1996 to 2002, for example, certain specialties experienced increases in the number of applicants to residency programs, such as anesthesiology, dermatology, and radiology; whereas, other specialties saw reduced demand for training slots, such as in family practice and general surgery. For example, U.S. medical school seniors filled 89% of the general surgery residency slots available in 1996, but only 75% of the available slots in 2002.

The relative number of physicians in certain geographies will also be affected by the attractiveness of that particular area of the country or practice location and style, such as rural versus urban or suburban.

Physicians’ retirement rates generate different estimates, too. Currently, 18% of physicians in the United States are older than 65—compared with 12.6% of the overall population. In certain states, the percentage of physicians older than 65 is substantially higher, in some cases more than 20%. Different analysts generate different expectations about how many physicians over age 65 will leave the workforce. The number of hours that doctors practice and their decisions about when they will retire, based on their personal financial circumstances, are quite varied. This makes calculations of the shortfall to be anticipated subject to a variety of interpretations

Substitution

There is a debate also over the question of substitution. If there are too few physicians in the United States, will a shortfall in supply be made up by increasing numbers of foreign medical graduates or by other non-physician practitioners?

New foreign medical graduates may make up perhaps as many as 6,000 positions nationally. This will not make up for the shortfall of between 3,000 and 10,000 per year of additional physicians who need to graduate and enter the workforce.

Substitution by non-physician practitioners will mitigate some of the effects of the shortfall. We can anticipate that the use of nurse practitioners, physician assistants, nurses, and health educators will increase in situations where they can substitute for lower intensity medical care—especially in primary care settings, outpatient environments, and as adjuncts to care delivered by proceduralists and surgeons of many types. This will make some difference in the overall expectation for reduced availability of physicians.

Given all of these inputs, all projections point to a shortage of physicians, but none of the analyses agree on the absolute size.

The Effects of the Shortage

In any event, the projected shortage will affect how hospitals support their various service lines and, thus, will impact on the work performed by hospitalists, intensivists, and other physicians who support that work in hospitals. Hospitals anticipate this effect at the intersection of the shortage with increasing demands for rapid throughput, thorough and safe care for patients, and accountability for clearly specified clinical outcomes. Hospitals are already worrying about how to staff neurosurgery, cardiology, and general surgery positions. Changes in how primary care is delivered will affect where patient referrals come from and hospitals’ relationship with their specialist physicians.

How Will a Shortage Affect Hospitalists?

Increasing demand for services: With fewer physicians choosing general or primary care practice, hospitalists will find increasing demand for their services as coverage for acute care. Fewer primary care physicians will be able to afford the luxury of inpatient practice and gravitate toward highly efficient outpatient office-based practice while referring acute care to their hospitalist colleagues and specialists to pick up the slack for specific procedures, hospital follow-up care and return on discharge.

Hospitalists will be responsible then for a larger population of inpatients, providing for comprehensive care management in coordinating the services for all the care needs of many different types of diagnoses.

Increasing span of influence: In addition, there will be increasing demand by procedure-oriented physicians for hospitalist coverage to improve their efficiency in providing acute specialty care. Some of this demand may spill into single-specialty outpatient and focused freestanding hospital environments. Hospitalists will be pulled to cover specialists, who find their efficiency and the volume of work required prohibits them from providing comprehensive inpatient care for complex patients. They will prefer to focus on procedural interventions. Orthopedic surgery, cardiac surgery, neurosurgery, and cardiology, in particular, are likely to be new clients for hospitalist services.

Increasing emphasis on multidisciplinary care: Given the demand for evidence-based outcomes, hospitalists will provide physician input into clinical care design for a greater variety of patients in an increasing span of clinical service lines. This will put a demand on hospitalists for skills related to teamwork, leadership, and management in group environments. It will also require hospitalists to become broadly knowledgeable about the skills and contributions of all other potential care providers.

The New Medical Staff

The looming physician shortage in the United States will significantly affect the demand for and the variety and scope of work that hospitalists perform. The number of medical specialties dependent on hospitalist services will broaden. And hospitals will turn to hospitalists as their primary medical staff partners, responsible for the majority of medical staff functions and responsibilities. TH

Mike Guthrie, MD, is executive in residence at the University of Colorado (Denver) School of Business, Program in Health Administration, and a faculty member of SHM’s Leadership Academy.

In March 2005, the Association of American Medical Colleges announced that America will face a shortage of between 85,000 and 200,000 physicians by 2020. The U.S. population is growing faster than the number of new physicians entering the workforce. How big the shortfall will be has been argued since last year, but most pundits expect there to be too few physicians—in total—to take care of the burgeoning population, especially the elderly.

If a shortage of physicians is to be anticipated, what effect might this have on hospitals and hospitalists?

Where Does the Number Come From?

The debate about the range of the projected shortfall of 85,000 to 200,000 physicians reflects several differing assumptions. All estimates are based on the ratio of physicians to the overall population. Different estimates are based on distinctive models for the necessary staffing of the medical enterprise. For example, prepaid medical groups that serve large populations of patients (e.g., Kaiser Permanente) have physician-per-capita ratios of up to 20% less than fee-for-service environments. A larger elderly population will likely demand more medical services per capita. So, the estimate of a shortfall depends on the model of medical care for 2020 anticipated to be predominant in 2020 and a calculation of usage rate per capita for services—again, especially among the elderly.

Work/life balance choices that recent medical school graduates make also add to the uncertainty of predictions concerning the relative size of the shortage in total and by specialty. Young men and women graduating today increasingly express a preference for reduced or more manageable hours of work per week, sometimes opting for shift work or other forms of more predictable workload. There is also an understanding that women physicians tend to work part-time in some stages of their career—especially when they are trying to balance the demands of starting and raising a young family. Many of their male spouses are making similar choices.

The Specialty Nature of the Shortfall

A relative shortfall in available physicians relates to the specialty choice of new residency graduates. From 1996 to 2002, for example, certain specialties experienced increases in the number of applicants to residency programs, such as anesthesiology, dermatology, and radiology; whereas, other specialties saw reduced demand for training slots, such as in family practice and general surgery. For example, U.S. medical school seniors filled 89% of the general surgery residency slots available in 1996, but only 75% of the available slots in 2002.

The relative number of physicians in certain geographies will also be affected by the attractiveness of that particular area of the country or practice location and style, such as rural versus urban or suburban.

Physicians’ retirement rates generate different estimates, too. Currently, 18% of physicians in the United States are older than 65—compared with 12.6% of the overall population. In certain states, the percentage of physicians older than 65 is substantially higher, in some cases more than 20%. Different analysts generate different expectations about how many physicians over age 65 will leave the workforce. The number of hours that doctors practice and their decisions about when they will retire, based on their personal financial circumstances, are quite varied. This makes calculations of the shortfall to be anticipated subject to a variety of interpretations

Substitution

There is a debate also over the question of substitution. If there are too few physicians in the United States, will a shortfall in supply be made up by increasing numbers of foreign medical graduates or by other non-physician practitioners?

New foreign medical graduates may make up perhaps as many as 6,000 positions nationally. This will not make up for the shortfall of between 3,000 and 10,000 per year of additional physicians who need to graduate and enter the workforce.

Substitution by non-physician practitioners will mitigate some of the effects of the shortfall. We can anticipate that the use of nurse practitioners, physician assistants, nurses, and health educators will increase in situations where they can substitute for lower intensity medical care—especially in primary care settings, outpatient environments, and as adjuncts to care delivered by proceduralists and surgeons of many types. This will make some difference in the overall expectation for reduced availability of physicians.

Given all of these inputs, all projections point to a shortage of physicians, but none of the analyses agree on the absolute size.

The Effects of the Shortage

In any event, the projected shortage will affect how hospitals support their various service lines and, thus, will impact on the work performed by hospitalists, intensivists, and other physicians who support that work in hospitals. Hospitals anticipate this effect at the intersection of the shortage with increasing demands for rapid throughput, thorough and safe care for patients, and accountability for clearly specified clinical outcomes. Hospitals are already worrying about how to staff neurosurgery, cardiology, and general surgery positions. Changes in how primary care is delivered will affect where patient referrals come from and hospitals’ relationship with their specialist physicians.

How Will a Shortage Affect Hospitalists?

Increasing demand for services: With fewer physicians choosing general or primary care practice, hospitalists will find increasing demand for their services as coverage for acute care. Fewer primary care physicians will be able to afford the luxury of inpatient practice and gravitate toward highly efficient outpatient office-based practice while referring acute care to their hospitalist colleagues and specialists to pick up the slack for specific procedures, hospital follow-up care and return on discharge.

Hospitalists will be responsible then for a larger population of inpatients, providing for comprehensive care management in coordinating the services for all the care needs of many different types of diagnoses.

Increasing span of influence: In addition, there will be increasing demand by procedure-oriented physicians for hospitalist coverage to improve their efficiency in providing acute specialty care. Some of this demand may spill into single-specialty outpatient and focused freestanding hospital environments. Hospitalists will be pulled to cover specialists, who find their efficiency and the volume of work required prohibits them from providing comprehensive inpatient care for complex patients. They will prefer to focus on procedural interventions. Orthopedic surgery, cardiac surgery, neurosurgery, and cardiology, in particular, are likely to be new clients for hospitalist services.

Increasing emphasis on multidisciplinary care: Given the demand for evidence-based outcomes, hospitalists will provide physician input into clinical care design for a greater variety of patients in an increasing span of clinical service lines. This will put a demand on hospitalists for skills related to teamwork, leadership, and management in group environments. It will also require hospitalists to become broadly knowledgeable about the skills and contributions of all other potential care providers.

The New Medical Staff

The looming physician shortage in the United States will significantly affect the demand for and the variety and scope of work that hospitalists perform. The number of medical specialties dependent on hospitalist services will broaden. And hospitals will turn to hospitalists as their primary medical staff partners, responsible for the majority of medical staff functions and responsibilities. TH

Mike Guthrie, MD, is executive in residence at the University of Colorado (Denver) School of Business, Program in Health Administration, and a faculty member of SHM’s Leadership Academy.

In March 2005, the Association of American Medical Colleges announced that America will face a shortage of between 85,000 and 200,000 physicians by 2020. The U.S. population is growing faster than the number of new physicians entering the workforce. How big the shortfall will be has been argued since last year, but most pundits expect there to be too few physicians—in total—to take care of the burgeoning population, especially the elderly.

If a shortage of physicians is to be anticipated, what effect might this have on hospitals and hospitalists?

Where Does the Number Come From?

The debate about the range of the projected shortfall of 85,000 to 200,000 physicians reflects several differing assumptions. All estimates are based on the ratio of physicians to the overall population. Different estimates are based on distinctive models for the necessary staffing of the medical enterprise. For example, prepaid medical groups that serve large populations of patients (e.g., Kaiser Permanente) have physician-per-capita ratios of up to 20% less than fee-for-service environments. A larger elderly population will likely demand more medical services per capita. So, the estimate of a shortfall depends on the model of medical care for 2020 anticipated to be predominant in 2020 and a calculation of usage rate per capita for services—again, especially among the elderly.

Work/life balance choices that recent medical school graduates make also add to the uncertainty of predictions concerning the relative size of the shortage in total and by specialty. Young men and women graduating today increasingly express a preference for reduced or more manageable hours of work per week, sometimes opting for shift work or other forms of more predictable workload. There is also an understanding that women physicians tend to work part-time in some stages of their career—especially when they are trying to balance the demands of starting and raising a young family. Many of their male spouses are making similar choices.

The Specialty Nature of the Shortfall

A relative shortfall in available physicians relates to the specialty choice of new residency graduates. From 1996 to 2002, for example, certain specialties experienced increases in the number of applicants to residency programs, such as anesthesiology, dermatology, and radiology; whereas, other specialties saw reduced demand for training slots, such as in family practice and general surgery. For example, U.S. medical school seniors filled 89% of the general surgery residency slots available in 1996, but only 75% of the available slots in 2002.

The relative number of physicians in certain geographies will also be affected by the attractiveness of that particular area of the country or practice location and style, such as rural versus urban or suburban.

Physicians’ retirement rates generate different estimates, too. Currently, 18% of physicians in the United States are older than 65—compared with 12.6% of the overall population. In certain states, the percentage of physicians older than 65 is substantially higher, in some cases more than 20%. Different analysts generate different expectations about how many physicians over age 65 will leave the workforce. The number of hours that doctors practice and their decisions about when they will retire, based on their personal financial circumstances, are quite varied. This makes calculations of the shortfall to be anticipated subject to a variety of interpretations

Substitution

There is a debate also over the question of substitution. If there are too few physicians in the United States, will a shortfall in supply be made up by increasing numbers of foreign medical graduates or by other non-physician practitioners?

New foreign medical graduates may make up perhaps as many as 6,000 positions nationally. This will not make up for the shortfall of between 3,000 and 10,000 per year of additional physicians who need to graduate and enter the workforce.

Substitution by non-physician practitioners will mitigate some of the effects of the shortfall. We can anticipate that the use of nurse practitioners, physician assistants, nurses, and health educators will increase in situations where they can substitute for lower intensity medical care—especially in primary care settings, outpatient environments, and as adjuncts to care delivered by proceduralists and surgeons of many types. This will make some difference in the overall expectation for reduced availability of physicians.

Given all of these inputs, all projections point to a shortage of physicians, but none of the analyses agree on the absolute size.

The Effects of the Shortage

In any event, the projected shortage will affect how hospitals support their various service lines and, thus, will impact on the work performed by hospitalists, intensivists, and other physicians who support that work in hospitals. Hospitals anticipate this effect at the intersection of the shortage with increasing demands for rapid throughput, thorough and safe care for patients, and accountability for clearly specified clinical outcomes. Hospitals are already worrying about how to staff neurosurgery, cardiology, and general surgery positions. Changes in how primary care is delivered will affect where patient referrals come from and hospitals’ relationship with their specialist physicians.

How Will a Shortage Affect Hospitalists?

Increasing demand for services: With fewer physicians choosing general or primary care practice, hospitalists will find increasing demand for their services as coverage for acute care. Fewer primary care physicians will be able to afford the luxury of inpatient practice and gravitate toward highly efficient outpatient office-based practice while referring acute care to their hospitalist colleagues and specialists to pick up the slack for specific procedures, hospital follow-up care and return on discharge.

Hospitalists will be responsible then for a larger population of inpatients, providing for comprehensive care management in coordinating the services for all the care needs of many different types of diagnoses.

Increasing span of influence: In addition, there will be increasing demand by procedure-oriented physicians for hospitalist coverage to improve their efficiency in providing acute specialty care. Some of this demand may spill into single-specialty outpatient and focused freestanding hospital environments. Hospitalists will be pulled to cover specialists, who find their efficiency and the volume of work required prohibits them from providing comprehensive inpatient care for complex patients. They will prefer to focus on procedural interventions. Orthopedic surgery, cardiac surgery, neurosurgery, and cardiology, in particular, are likely to be new clients for hospitalist services.

Increasing emphasis on multidisciplinary care: Given the demand for evidence-based outcomes, hospitalists will provide physician input into clinical care design for a greater variety of patients in an increasing span of clinical service lines. This will put a demand on hospitalists for skills related to teamwork, leadership, and management in group environments. It will also require hospitalists to become broadly knowledgeable about the skills and contributions of all other potential care providers.

The New Medical Staff

The looming physician shortage in the United States will significantly affect the demand for and the variety and scope of work that hospitalists perform. The number of medical specialties dependent on hospitalist services will broaden. And hospitals will turn to hospitalists as their primary medical staff partners, responsible for the majority of medical staff functions and responsibilities. TH

Mike Guthrie, MD, is executive in residence at the University of Colorado (Denver) School of Business, Program in Health Administration, and a faculty member of SHM’s Leadership Academy.

The purported benefits of hospital medicine, including reduced lengths of stay, cost savings and quality improvement for the hospital, and higher satisfaction for primary care physicians and patients, have been widely discussed. But are these positive outcomes always ensured when a hospital or a medical group decides to start a hospitalist program?

If the program is launched without adequate planning, a viable business plan, sufficient staffing, or other basic components of any successful business enterprise, the results may disappoint. The program may not deliver desired outcomes in terms of quality or cost savings. Hospitalist staff may become disillusioned, overworked, or burned out and then leave. The program might even fail, which is doubly problematic once physicians and hospital administrators have gotten used to the advantages of having hospitalist coverage in their facility.

What Not to Do … and How to Fix It

A hospitalist service started by Lewis-Gale Clinic, a multi-specialty medical group in Salem, Va., and practicing at 521-bed Lewis-Gale Medical Center, experienced serious problems after its launch in 1997.

“Our program initially wasn’t a true hospitalist program per se, but more like a service provided to internists in the medical group,” says Harsukh Patolia, MD, the hospitalist program’s medical director. “I was the first person hired. I made it clear that I wanted to be a hospitalist. But there were not many models available for us to base our program on.”

Demand was great from clinic physicians, who no longer had time to see their patients at the hospital, says Dr. Patolia. Three additional hospitalists were hired, but by 1999, one had left and the others were stressed out and overworked. “We were working very hard,” he says. But the program was dependent on locum tenens physicians to fill shifts, and quality was starting to suffer. “I’m not sure we were on the brink of failure, but there was a lot of dissatisfaction.”

Jon Ness, then the medical group’s administrator, identified a problem with the hospitalist service soon after he started work in Salem in 1999. “My sense was that both the hospital and medical staff really wanted the program and didn’t want to see it fail. But they didn’t understand why we were having so many challenges with it,” he says. “The first thing we did was a thorough clinical and administrative review of the program. The more information I collected, the more concerned I got.”

Recognizing that there wasn’t enough expertise within the organization to sort out the problems, Ness contacted Colorado Springs, Colo., consultant Roger Heroux of Hospitalist Management Resources, LLC. Additionally, he approached Lewis-Gale Medical Center’s new CEO, James Thweatt, who also realized that there was a problem with the program.

“If they hadn’t come to me, I would have gone to them with my recommendation for a consultant,” adds Thweatt. Basically, there were serious lacks in terms of logistical support for the service, of clarity in its strategic goals, and of authority for the practice’s leadership, while its relationship with the rest of the clinic was also deteriorating.

“With the changing face of healthcare, a viable hospitalist program was a necessity,” Thweatt says. He also had to satisfy the demands of physicians—not only those belonging to the group practice but also independent primary care practitioners in the community—or else they might take their patients to a competing hospital.

Ness and Heroux surveyed physicians about their needs and desires for the program, visiting a number of key physicians in their offices. Another challenge they handled was to negotiate a contract with the hospital for the hospitalists’ services, including a subsidy to reflect their 24/7 coverage in the hospital. Then they needed to agree on appropriate quality and financial performance measures by which to gauge the program’s success.

“With Roger’s help, we all got smarter about what a true hospitalist program was,” says Ness. “What I discovered was that a hospitalist program is no different than any other significant business venture. It needs its own goals, leadership, and overarching business plan. You can’t just put it in place and assume that you’ll be successful. It requires just as much discipline, rigor, and hard work as other businesses.”

Practice Management Tasks

A comprehensive list of why some hospitalist programs risk failure, including problems with recruitment, retention, scheduling, compensation, communication with primary physicians, buy-in, marketing, data analysis, financial performance, and return on investment for the hospital, would closely track with the content of any hospitalist practice management course. One such course, “Best Practices in Managing a Hospital Medicine Program,” sponsored by SHM and presented at UCSF’s Management of the Hospitalized Patient meeting in San Francisco on October 11 by some of the field’s top consultants and practice leaders, covered these topics.

Heroux was on the UCSF faculty, and he presented his model of the Fourth Generation hospitalist practice that has evolved from a simple rounding model with daily assignments of outpatient physicians, a rotational model with one-week assignments of outpatient physicians, and a group of dedicated hospitalists who lack administrative support. The Fourth Generation hospitalist program is a sustainable, dedicated program that enjoys full clinical and administrative support, including a practice manager and a case manager.

Such a practice provides dedicated 24-hour coverage with realistic staffing ratios, employs effective practice leadership, is strategically aligned with the hospital and medical community, and utilizes a financial management system and data sets for benchmarking of key performance measures demonstrating its value. Without these components in place, Heroux says, the hospitalist program risks serious dysfunction and eventual failure.

Reflecting on his work with Lewis-Gale and other clients, Heroux believes it is important to be disciplined and deliberate about evaluating the real need for a hospitalist service in the community. “Talk to your medical staff. Find out what they want and need from the service. Then prioritize those needs because you can’t do everything at once, and build your business plan on how you’ll meet the identified priorities. Let them drive your staffing patterns and your cost savings targets,” he says. “And make your program data-driven from the start.”

When Heroux started working with Lewis-Gale, they had none of these components. “They were trying to meet the needs without the infrastructure, and that is how they got into trouble,” he says.

Why are some hospitalist programs launched without this kind of support or the business planning that would be de rigueur for any hospital launching a new imaging center or outpatient surgery center? Perhaps the lack of capital investment on equipment for a hospitalist service leads to a casual attitude about doing the needed homework. Or else misconceptions blind hospital administrators to the real complexities and financial implications of a hospitalist program.

“I think there is a mentality sometimes that says, ‘Hey, we’re good managers, we can do this,’ ” suggests Heroux. “Sometimes they don’t know what they don’t know. Many times they don’t want to spend the time and money or get the help [they need] to do it right.”

Do Your Homework

Bruce Becker, MD, a family practice physician and chief medical officer at Medical Center Hospital in Odessa, Texas, spent two years helping his institution do its homework and gathering support within the medical community before the hospital’s board of directors approved a plan for a hospitalist program in July 2006.

“We started exploring a hospitalist program two years ago,” says Dr. Becker. A national company made a proposal to the hospital to develop a turnkey program. “We also attempted to work with private physicians and with the local medical school but couldn’t come to an agreement at that time.”

When the board was first approached with a $100,000 proposal for a consultant’s study, it had the usual concerns about return on investment and volume of demand, Dr. Becker says. But the biggest barrier to the new service was an attitude within the local medical community that hospitalists would disrupt continuity of care and longstanding relationships between physicians and their patients. To address this discomfort, “we decided to go step by step with our consultant—polling the medical staff, administration and board members,” says Dr. Becker. Their responses suggested that sufficient demand existed.

Dr. Becker asked a physician he knew who had set up a hospitalist program in another community to speak to the hospital board. He and several colleagues attended an SHM conference to learn more about the basics of operating a program. Eventually, the board approved a request for proposals (RFP), which was sent to seven potential contractors, both local groups and national companies.

“What we were going through was an educational process,” explains Dr. Becker. “I could see a visible change taking place on the faces of board members. Two years ago, they weren’t ready, and if I had tried to push it, they would have said no. Now they are ready, and our medical staff is much more accepting.” Hospitalists are now being interviewed for the new program, with a projected launch date of July 2007.

The Importance of Leadership

Winthrop Whitcomb, MD, a practicing hospitalist at Mercy Medical Center in Springfield, Mass., and co-founder of SHM, believes the absence of strong practice leadership by someone with leadership and management skills who is based on site and devoted to hospital medicine is the number one reason why hospitalist programs fail. He tells the story of a hospitalist program started by a multi-specialty group that assigned as its medical director a primary care physician who had a busy office practice.

“That leader wasn’t able to have much contact with the group or the day-in, day-out challenges of its growing caseload,” relates Dr. Whitcomb. “The hospitalists began to get demoralized, feeling that no one was advocating for them.” A consultant recommended hiring an on-site leader for the program. The next medical director had some knowledge of medical management and hospital medicine but was only one-quarter-time dedicated to the hospitalist program. Problems of morale, turnover, and service quality continued.

“The leader instituted a few good things, including an incentive-based compensation program, but ultimately was ineffective and unable to develop the staff’s trust,” says Dr. Whitcomb. “I could tell that story over and over again. To put it another way, a lot of the pitfalls can be overcome with a good, strong leader.” Often, programs such as the one he describes flounder but continue to limp along for years, until a good leader comes along to place the program on a stronger footing.

In other cases, a new hospitalist program might be launched with just one physician and limited coverage, with plans to grow from there. “That’s fine, as long as that person you’re starting with is serving in a leadership capacity as well as seeing patients. It’s hard to find a good leader. But you will need somebody who is driving the bus in fairly short order,” says Dr. Whitcomb.

Growth Pains and Other Common Problems

John Nelson, MD, a hospitalist and consultant in Bellevue, Wash., co-founder of SHM, and columnist for The Hospitalist, points out some other common causes of hospitalist program collapse, including the failure to appreciate how rapidly the program will grow or to have a plan for how to deal with growth. “It doesn’t take a year to reach your projections,” he advises. “Suddenly, you’ve got a bigger caseload than the original doctors can handle. They get overwhelmed and burned out and then leave.”

If the hospitalists feel no ownership or personal investment in the practice’s success, they may develop a kind of civil service mentality about the job instead of a customer service mindset, says Dr. Nelson. Combine that with a straight salary instead of productivity incentives, and they may lack the necessary commitment to the program’s quality and growth.

“I also work as a consultant to help other hospitals start hospitalist practices. I’ve had a lot of experience with programs that never got off the ground,” he says. In one case, staff did an analysis to find out how much it would cost to support the program and then decided not to go forward. In that case, the hospital was reimbursed more on per diems than diagnosis-related groups, so reduced lengths of stay would not have benefited the facility.

In other cases, hospitals have not gone forward because of local medical politics or unfounded suspicions about hospital medicine. The dominant local multi-specialty group may insist on operating the hospitalist program itself, refusing to let anyone else do it. But the group makes unrealistic assumptions about workload or else wants to charge the same high overhead rate to the hospitalists that its clinic doctors pay, which is not feasible for a hospitalist program.

“I came to my current position because of a medical group that wanted to control the hospital medicine practice,” says Dr. Nelson. “But then they got busy and exhausted and wanted to quit being hospitalists. At that point, the hospital administrator panicked.”

Learn from Success

Thweatt believes that the hospitalist program at Lewis-Gale Medical Center, which now directly employs the hospitalists, is doing well, with seven full-time dedicated hospitalists. “Not that it’s always easy, but it’s no different than running any other business. If this program went away tomorrow, I think I’d be tarred and feathered by the medical staff,” he quips.

Dr. Patolia adds that the program has a compensation structure based entirely on productivity and a schedule that ensures 24-hour coverage. “We work as a team, and we depend on each other so much. We’re all committed people who want to be hospitalists,” he says. “Right now, I love being a hospitalist to such a degree that I can’t imagine doing anything else.”

Recently, a senior vice president from the hospital’s parent company, Hospital Corporation of America (HCA), visited Lewis-Gale to learn how to replicate its successful hospitalist program in all HCA hospitals.

Jon Ness, now chief operating officer of Billings Clinic in Billings, Mont., says one of the first things he did in his new job was to develop a hospitalist program. “I brought in Roger Heroux to do the evaluation,” he says. The process followed a familiar checklist: defining program goals, lining up clinic and hospital support, assessing manpower needs, and developing a data support system.

The Billings program was launched in January 2006 and today employs six full-time hospitalists. In contrast to the early days at Lewis-Gale, however, “we started out with a strong, deep business plan.”

For more information on the Fourth Generation hospitalist practice, contact Roger Heroux, Partner, Hospitalist Management Resources, LLC, 5490 Creighton Ct., Colorado Springs, CO 80918, 719/331-7119, or [email protected]. Visit the Society of Hospital Medicine Web site (www.hospitalmedicine.org) for information on practice management courses and other educational resources, including audiotapes of “Best Practices in Managing a Hospital Medicine Program.” TH

Larry Beresford is a regular contributor to The Hospitalist.

The purported benefits of hospital medicine, including reduced lengths of stay, cost savings and quality improvement for the hospital, and higher satisfaction for primary care physicians and patients, have been widely discussed. But are these positive outcomes always ensured when a hospital or a medical group decides to start a hospitalist program?

If the program is launched without adequate planning, a viable business plan, sufficient staffing, or other basic components of any successful business enterprise, the results may disappoint. The program may not deliver desired outcomes in terms of quality or cost savings. Hospitalist staff may become disillusioned, overworked, or burned out and then leave. The program might even fail, which is doubly problematic once physicians and hospital administrators have gotten used to the advantages of having hospitalist coverage in their facility.

What Not to Do … and How to Fix It

A hospitalist service started by Lewis-Gale Clinic, a multi-specialty medical group in Salem, Va., and practicing at 521-bed Lewis-Gale Medical Center, experienced serious problems after its launch in 1997.

“Our program initially wasn’t a true hospitalist program per se, but more like a service provided to internists in the medical group,” says Harsukh Patolia, MD, the hospitalist program’s medical director. “I was the first person hired. I made it clear that I wanted to be a hospitalist. But there were not many models available for us to base our program on.”

Demand was great from clinic physicians, who no longer had time to see their patients at the hospital, says Dr. Patolia. Three additional hospitalists were hired, but by 1999, one had left and the others were stressed out and overworked. “We were working very hard,” he says. But the program was dependent on locum tenens physicians to fill shifts, and quality was starting to suffer. “I’m not sure we were on the brink of failure, but there was a lot of dissatisfaction.”

Jon Ness, then the medical group’s administrator, identified a problem with the hospitalist service soon after he started work in Salem in 1999. “My sense was that both the hospital and medical staff really wanted the program and didn’t want to see it fail. But they didn’t understand why we were having so many challenges with it,” he says. “The first thing we did was a thorough clinical and administrative review of the program. The more information I collected, the more concerned I got.”

Recognizing that there wasn’t enough expertise within the organization to sort out the problems, Ness contacted Colorado Springs, Colo., consultant Roger Heroux of Hospitalist Management Resources, LLC. Additionally, he approached Lewis-Gale Medical Center’s new CEO, James Thweatt, who also realized that there was a problem with the program.

“If they hadn’t come to me, I would have gone to them with my recommendation for a consultant,” adds Thweatt. Basically, there were serious lacks in terms of logistical support for the service, of clarity in its strategic goals, and of authority for the practice’s leadership, while its relationship with the rest of the clinic was also deteriorating.

“With the changing face of healthcare, a viable hospitalist program was a necessity,” Thweatt says. He also had to satisfy the demands of physicians—not only those belonging to the group practice but also independent primary care practitioners in the community—or else they might take their patients to a competing hospital.

Ness and Heroux surveyed physicians about their needs and desires for the program, visiting a number of key physicians in their offices. Another challenge they handled was to negotiate a contract with the hospital for the hospitalists’ services, including a subsidy to reflect their 24/7 coverage in the hospital. Then they needed to agree on appropriate quality and financial performance measures by which to gauge the program’s success.

“With Roger’s help, we all got smarter about what a true hospitalist program was,” says Ness. “What I discovered was that a hospitalist program is no different than any other significant business venture. It needs its own goals, leadership, and overarching business plan. You can’t just put it in place and assume that you’ll be successful. It requires just as much discipline, rigor, and hard work as other businesses.”

Practice Management Tasks

A comprehensive list of why some hospitalist programs risk failure, including problems with recruitment, retention, scheduling, compensation, communication with primary physicians, buy-in, marketing, data analysis, financial performance, and return on investment for the hospital, would closely track with the content of any hospitalist practice management course. One such course, “Best Practices in Managing a Hospital Medicine Program,” sponsored by SHM and presented at UCSF’s Management of the Hospitalized Patient meeting in San Francisco on October 11 by some of the field’s top consultants and practice leaders, covered these topics.

Heroux was on the UCSF faculty, and he presented his model of the Fourth Generation hospitalist practice that has evolved from a simple rounding model with daily assignments of outpatient physicians, a rotational model with one-week assignments of outpatient physicians, and a group of dedicated hospitalists who lack administrative support. The Fourth Generation hospitalist program is a sustainable, dedicated program that enjoys full clinical and administrative support, including a practice manager and a case manager.

Such a practice provides dedicated 24-hour coverage with realistic staffing ratios, employs effective practice leadership, is strategically aligned with the hospital and medical community, and utilizes a financial management system and data sets for benchmarking of key performance measures demonstrating its value. Without these components in place, Heroux says, the hospitalist program risks serious dysfunction and eventual failure.

Reflecting on his work with Lewis-Gale and other clients, Heroux believes it is important to be disciplined and deliberate about evaluating the real need for a hospitalist service in the community. “Talk to your medical staff. Find out what they want and need from the service. Then prioritize those needs because you can’t do everything at once, and build your business plan on how you’ll meet the identified priorities. Let them drive your staffing patterns and your cost savings targets,” he says. “And make your program data-driven from the start.”

When Heroux started working with Lewis-Gale, they had none of these components. “They were trying to meet the needs without the infrastructure, and that is how they got into trouble,” he says.

Why are some hospitalist programs launched without this kind of support or the business planning that would be de rigueur for any hospital launching a new imaging center or outpatient surgery center? Perhaps the lack of capital investment on equipment for a hospitalist service leads to a casual attitude about doing the needed homework. Or else misconceptions blind hospital administrators to the real complexities and financial implications of a hospitalist program.

“I think there is a mentality sometimes that says, ‘Hey, we’re good managers, we can do this,’ ” suggests Heroux. “Sometimes they don’t know what they don’t know. Many times they don’t want to spend the time and money or get the help [they need] to do it right.”

Do Your Homework

Bruce Becker, MD, a family practice physician and chief medical officer at Medical Center Hospital in Odessa, Texas, spent two years helping his institution do its homework and gathering support within the medical community before the hospital’s board of directors approved a plan for a hospitalist program in July 2006.

“We started exploring a hospitalist program two years ago,” says Dr. Becker. A national company made a proposal to the hospital to develop a turnkey program. “We also attempted to work with private physicians and with the local medical school but couldn’t come to an agreement at that time.”

When the board was first approached with a $100,000 proposal for a consultant’s study, it had the usual concerns about return on investment and volume of demand, Dr. Becker says. But the biggest barrier to the new service was an attitude within the local medical community that hospitalists would disrupt continuity of care and longstanding relationships between physicians and their patients. To address this discomfort, “we decided to go step by step with our consultant—polling the medical staff, administration and board members,” says Dr. Becker. Their responses suggested that sufficient demand existed.

Dr. Becker asked a physician he knew who had set up a hospitalist program in another community to speak to the hospital board. He and several colleagues attended an SHM conference to learn more about the basics of operating a program. Eventually, the board approved a request for proposals (RFP), which was sent to seven potential contractors, both local groups and national companies.

“What we were going through was an educational process,” explains Dr. Becker. “I could see a visible change taking place on the faces of board members. Two years ago, they weren’t ready, and if I had tried to push it, they would have said no. Now they are ready, and our medical staff is much more accepting.” Hospitalists are now being interviewed for the new program, with a projected launch date of July 2007.

The Importance of Leadership

Winthrop Whitcomb, MD, a practicing hospitalist at Mercy Medical Center in Springfield, Mass., and co-founder of SHM, believes the absence of strong practice leadership by someone with leadership and management skills who is based on site and devoted to hospital medicine is the number one reason why hospitalist programs fail. He tells the story of a hospitalist program started by a multi-specialty group that assigned as its medical director a primary care physician who had a busy office practice.

“That leader wasn’t able to have much contact with the group or the day-in, day-out challenges of its growing caseload,” relates Dr. Whitcomb. “The hospitalists began to get demoralized, feeling that no one was advocating for them.” A consultant recommended hiring an on-site leader for the program. The next medical director had some knowledge of medical management and hospital medicine but was only one-quarter-time dedicated to the hospitalist program. Problems of morale, turnover, and service quality continued.

“The leader instituted a few good things, including an incentive-based compensation program, but ultimately was ineffective and unable to develop the staff’s trust,” says Dr. Whitcomb. “I could tell that story over and over again. To put it another way, a lot of the pitfalls can be overcome with a good, strong leader.” Often, programs such as the one he describes flounder but continue to limp along for years, until a good leader comes along to place the program on a stronger footing.

In other cases, a new hospitalist program might be launched with just one physician and limited coverage, with plans to grow from there. “That’s fine, as long as that person you’re starting with is serving in a leadership capacity as well as seeing patients. It’s hard to find a good leader. But you will need somebody who is driving the bus in fairly short order,” says Dr. Whitcomb.

Growth Pains and Other Common Problems

John Nelson, MD, a hospitalist and consultant in Bellevue, Wash., co-founder of SHM, and columnist for The Hospitalist, points out some other common causes of hospitalist program collapse, including the failure to appreciate how rapidly the program will grow or to have a plan for how to deal with growth. “It doesn’t take a year to reach your projections,” he advises. “Suddenly, you’ve got a bigger caseload than the original doctors can handle. They get overwhelmed and burned out and then leave.”

If the hospitalists feel no ownership or personal investment in the practice’s success, they may develop a kind of civil service mentality about the job instead of a customer service mindset, says Dr. Nelson. Combine that with a straight salary instead of productivity incentives, and they may lack the necessary commitment to the program’s quality and growth.

“I also work as a consultant to help other hospitals start hospitalist practices. I’ve had a lot of experience with programs that never got off the ground,” he says. In one case, staff did an analysis to find out how much it would cost to support the program and then decided not to go forward. In that case, the hospital was reimbursed more on per diems than diagnosis-related groups, so reduced lengths of stay would not have benefited the facility.

In other cases, hospitals have not gone forward because of local medical politics or unfounded suspicions about hospital medicine. The dominant local multi-specialty group may insist on operating the hospitalist program itself, refusing to let anyone else do it. But the group makes unrealistic assumptions about workload or else wants to charge the same high overhead rate to the hospitalists that its clinic doctors pay, which is not feasible for a hospitalist program.

“I came to my current position because of a medical group that wanted to control the hospital medicine practice,” says Dr. Nelson. “But then they got busy and exhausted and wanted to quit being hospitalists. At that point, the hospital administrator panicked.”

Learn from Success

Thweatt believes that the hospitalist program at Lewis-Gale Medical Center, which now directly employs the hospitalists, is doing well, with seven full-time dedicated hospitalists. “Not that it’s always easy, but it’s no different than running any other business. If this program went away tomorrow, I think I’d be tarred and feathered by the medical staff,” he quips.

Dr. Patolia adds that the program has a compensation structure based entirely on productivity and a schedule that ensures 24-hour coverage. “We work as a team, and we depend on each other so much. We’re all committed people who want to be hospitalists,” he says. “Right now, I love being a hospitalist to such a degree that I can’t imagine doing anything else.”

Recently, a senior vice president from the hospital’s parent company, Hospital Corporation of America (HCA), visited Lewis-Gale to learn how to replicate its successful hospitalist program in all HCA hospitals.

Jon Ness, now chief operating officer of Billings Clinic in Billings, Mont., says one of the first things he did in his new job was to develop a hospitalist program. “I brought in Roger Heroux to do the evaluation,” he says. The process followed a familiar checklist: defining program goals, lining up clinic and hospital support, assessing manpower needs, and developing a data support system.

The Billings program was launched in January 2006 and today employs six full-time hospitalists. In contrast to the early days at Lewis-Gale, however, “we started out with a strong, deep business plan.”

For more information on the Fourth Generation hospitalist practice, contact Roger Heroux, Partner, Hospitalist Management Resources, LLC, 5490 Creighton Ct., Colorado Springs, CO 80918, 719/331-7119, or [email protected]. Visit the Society of Hospital Medicine Web site (www.hospitalmedicine.org) for information on practice management courses and other educational resources, including audiotapes of “Best Practices in Managing a Hospital Medicine Program.” TH

Larry Beresford is a regular contributor to The Hospitalist.

The purported benefits of hospital medicine, including reduced lengths of stay, cost savings and quality improvement for the hospital, and higher satisfaction for primary care physicians and patients, have been widely discussed. But are these positive outcomes always ensured when a hospital or a medical group decides to start a hospitalist program?

If the program is launched without adequate planning, a viable business plan, sufficient staffing, or other basic components of any successful business enterprise, the results may disappoint. The program may not deliver desired outcomes in terms of quality or cost savings. Hospitalist staff may become disillusioned, overworked, or burned out and then leave. The program might even fail, which is doubly problematic once physicians and hospital administrators have gotten used to the advantages of having hospitalist coverage in their facility.

What Not to Do … and How to Fix It

A hospitalist service started by Lewis-Gale Clinic, a multi-specialty medical group in Salem, Va., and practicing at 521-bed Lewis-Gale Medical Center, experienced serious problems after its launch in 1997.

“Our program initially wasn’t a true hospitalist program per se, but more like a service provided to internists in the medical group,” says Harsukh Patolia, MD, the hospitalist program’s medical director. “I was the first person hired. I made it clear that I wanted to be a hospitalist. But there were not many models available for us to base our program on.”

Demand was great from clinic physicians, who no longer had time to see their patients at the hospital, says Dr. Patolia. Three additional hospitalists were hired, but by 1999, one had left and the others were stressed out and overworked. “We were working very hard,” he says. But the program was dependent on locum tenens physicians to fill shifts, and quality was starting to suffer. “I’m not sure we were on the brink of failure, but there was a lot of dissatisfaction.”

Jon Ness, then the medical group’s administrator, identified a problem with the hospitalist service soon after he started work in Salem in 1999. “My sense was that both the hospital and medical staff really wanted the program and didn’t want to see it fail. But they didn’t understand why we were having so many challenges with it,” he says. “The first thing we did was a thorough clinical and administrative review of the program. The more information I collected, the more concerned I got.”

Recognizing that there wasn’t enough expertise within the organization to sort out the problems, Ness contacted Colorado Springs, Colo., consultant Roger Heroux of Hospitalist Management Resources, LLC. Additionally, he approached Lewis-Gale Medical Center’s new CEO, James Thweatt, who also realized that there was a problem with the program.

“If they hadn’t come to me, I would have gone to them with my recommendation for a consultant,” adds Thweatt. Basically, there were serious lacks in terms of logistical support for the service, of clarity in its strategic goals, and of authority for the practice’s leadership, while its relationship with the rest of the clinic was also deteriorating.

“With the changing face of healthcare, a viable hospitalist program was a necessity,” Thweatt says. He also had to satisfy the demands of physicians—not only those belonging to the group practice but also independent primary care practitioners in the community—or else they might take their patients to a competing hospital.

Ness and Heroux surveyed physicians about their needs and desires for the program, visiting a number of key physicians in their offices. Another challenge they handled was to negotiate a contract with the hospital for the hospitalists’ services, including a subsidy to reflect their 24/7 coverage in the hospital. Then they needed to agree on appropriate quality and financial performance measures by which to gauge the program’s success.

“With Roger’s help, we all got smarter about what a true hospitalist program was,” says Ness. “What I discovered was that a hospitalist program is no different than any other significant business venture. It needs its own goals, leadership, and overarching business plan. You can’t just put it in place and assume that you’ll be successful. It requires just as much discipline, rigor, and hard work as other businesses.”

Practice Management Tasks

A comprehensive list of why some hospitalist programs risk failure, including problems with recruitment, retention, scheduling, compensation, communication with primary physicians, buy-in, marketing, data analysis, financial performance, and return on investment for the hospital, would closely track with the content of any hospitalist practice management course. One such course, “Best Practices in Managing a Hospital Medicine Program,” sponsored by SHM and presented at UCSF’s Management of the Hospitalized Patient meeting in San Francisco on October 11 by some of the field’s top consultants and practice leaders, covered these topics.

Heroux was on the UCSF faculty, and he presented his model of the Fourth Generation hospitalist practice that has evolved from a simple rounding model with daily assignments of outpatient physicians, a rotational model with one-week assignments of outpatient physicians, and a group of dedicated hospitalists who lack administrative support. The Fourth Generation hospitalist program is a sustainable, dedicated program that enjoys full clinical and administrative support, including a practice manager and a case manager.

Such a practice provides dedicated 24-hour coverage with realistic staffing ratios, employs effective practice leadership, is strategically aligned with the hospital and medical community, and utilizes a financial management system and data sets for benchmarking of key performance measures demonstrating its value. Without these components in place, Heroux says, the hospitalist program risks serious dysfunction and eventual failure.

Reflecting on his work with Lewis-Gale and other clients, Heroux believes it is important to be disciplined and deliberate about evaluating the real need for a hospitalist service in the community. “Talk to your medical staff. Find out what they want and need from the service. Then prioritize those needs because you can’t do everything at once, and build your business plan on how you’ll meet the identified priorities. Let them drive your staffing patterns and your cost savings targets,” he says. “And make your program data-driven from the start.”

When Heroux started working with Lewis-Gale, they had none of these components. “They were trying to meet the needs without the infrastructure, and that is how they got into trouble,” he says.

Why are some hospitalist programs launched without this kind of support or the business planning that would be de rigueur for any hospital launching a new imaging center or outpatient surgery center? Perhaps the lack of capital investment on equipment for a hospitalist service leads to a casual attitude about doing the needed homework. Or else misconceptions blind hospital administrators to the real complexities and financial implications of a hospitalist program.

“I think there is a mentality sometimes that says, ‘Hey, we’re good managers, we can do this,’ ” suggests Heroux. “Sometimes they don’t know what they don’t know. Many times they don’t want to spend the time and money or get the help [they need] to do it right.”

Do Your Homework

Bruce Becker, MD, a family practice physician and chief medical officer at Medical Center Hospital in Odessa, Texas, spent two years helping his institution do its homework and gathering support within the medical community before the hospital’s board of directors approved a plan for a hospitalist program in July 2006.

“We started exploring a hospitalist program two years ago,” says Dr. Becker. A national company made a proposal to the hospital to develop a turnkey program. “We also attempted to work with private physicians and with the local medical school but couldn’t come to an agreement at that time.”

When the board was first approached with a $100,000 proposal for a consultant’s study, it had the usual concerns about return on investment and volume of demand, Dr. Becker says. But the biggest barrier to the new service was an attitude within the local medical community that hospitalists would disrupt continuity of care and longstanding relationships between physicians and their patients. To address this discomfort, “we decided to go step by step with our consultant—polling the medical staff, administration and board members,” says Dr. Becker. Their responses suggested that sufficient demand existed.

Dr. Becker asked a physician he knew who had set up a hospitalist program in another community to speak to the hospital board. He and several colleagues attended an SHM conference to learn more about the basics of operating a program. Eventually, the board approved a request for proposals (RFP), which was sent to seven potential contractors, both local groups and national companies.

“What we were going through was an educational process,” explains Dr. Becker. “I could see a visible change taking place on the faces of board members. Two years ago, they weren’t ready, and if I had tried to push it, they would have said no. Now they are ready, and our medical staff is much more accepting.” Hospitalists are now being interviewed for the new program, with a projected launch date of July 2007.

The Importance of Leadership

Winthrop Whitcomb, MD, a practicing hospitalist at Mercy Medical Center in Springfield, Mass., and co-founder of SHM, believes the absence of strong practice leadership by someone with leadership and management skills who is based on site and devoted to hospital medicine is the number one reason why hospitalist programs fail. He tells the story of a hospitalist program started by a multi-specialty group that assigned as its medical director a primary care physician who had a busy office practice.

“That leader wasn’t able to have much contact with the group or the day-in, day-out challenges of its growing caseload,” relates Dr. Whitcomb. “The hospitalists began to get demoralized, feeling that no one was advocating for them.” A consultant recommended hiring an on-site leader for the program. The next medical director had some knowledge of medical management and hospital medicine but was only one-quarter-time dedicated to the hospitalist program. Problems of morale, turnover, and service quality continued.

“The leader instituted a few good things, including an incentive-based compensation program, but ultimately was ineffective and unable to develop the staff’s trust,” says Dr. Whitcomb. “I could tell that story over and over again. To put it another way, a lot of the pitfalls can be overcome with a good, strong leader.” Often, programs such as the one he describes flounder but continue to limp along for years, until a good leader comes along to place the program on a stronger footing.

In other cases, a new hospitalist program might be launched with just one physician and limited coverage, with plans to grow from there. “That’s fine, as long as that person you’re starting with is serving in a leadership capacity as well as seeing patients. It’s hard to find a good leader. But you will need somebody who is driving the bus in fairly short order,” says Dr. Whitcomb.

Growth Pains and Other Common Problems

John Nelson, MD, a hospitalist and consultant in Bellevue, Wash., co-founder of SHM, and columnist for The Hospitalist, points out some other common causes of hospitalist program collapse, including the failure to appreciate how rapidly the program will grow or to have a plan for how to deal with growth. “It doesn’t take a year to reach your projections,” he advises. “Suddenly, you’ve got a bigger caseload than the original doctors can handle. They get overwhelmed and burned out and then leave.”

If the hospitalists feel no ownership or personal investment in the practice’s success, they may develop a kind of civil service mentality about the job instead of a customer service mindset, says Dr. Nelson. Combine that with a straight salary instead of productivity incentives, and they may lack the necessary commitment to the program’s quality and growth.

“I also work as a consultant to help other hospitals start hospitalist practices. I’ve had a lot of experience with programs that never got off the ground,” he says. In one case, staff did an analysis to find out how much it would cost to support the program and then decided not to go forward. In that case, the hospital was reimbursed more on per diems than diagnosis-related groups, so reduced lengths of stay would not have benefited the facility.

In other cases, hospitals have not gone forward because of local medical politics or unfounded suspicions about hospital medicine. The dominant local multi-specialty group may insist on operating the hospitalist program itself, refusing to let anyone else do it. But the group makes unrealistic assumptions about workload or else wants to charge the same high overhead rate to the hospitalists that its clinic doctors pay, which is not feasible for a hospitalist program.

“I came to my current position because of a medical group that wanted to control the hospital medicine practice,” says Dr. Nelson. “But then they got busy and exhausted and wanted to quit being hospitalists. At that point, the hospital administrator panicked.”

Learn from Success

Thweatt believes that the hospitalist program at Lewis-Gale Medical Center, which now directly employs the hospitalists, is doing well, with seven full-time dedicated hospitalists. “Not that it’s always easy, but it’s no different than running any other business. If this program went away tomorrow, I think I’d be tarred and feathered by the medical staff,” he quips.

Dr. Patolia adds that the program has a compensation structure based entirely on productivity and a schedule that ensures 24-hour coverage. “We work as a team, and we depend on each other so much. We’re all committed people who want to be hospitalists,” he says. “Right now, I love being a hospitalist to such a degree that I can’t imagine doing anything else.”

Recently, a senior vice president from the hospital’s parent company, Hospital Corporation of America (HCA), visited Lewis-Gale to learn how to replicate its successful hospitalist program in all HCA hospitals.

Jon Ness, now chief operating officer of Billings Clinic in Billings, Mont., says one of the first things he did in his new job was to develop a hospitalist program. “I brought in Roger Heroux to do the evaluation,” he says. The process followed a familiar checklist: defining program goals, lining up clinic and hospital support, assessing manpower needs, and developing a data support system.

The Billings program was launched in January 2006 and today employs six full-time hospitalists. In contrast to the early days at Lewis-Gale, however, “we started out with a strong, deep business plan.”

For more information on the Fourth Generation hospitalist practice, contact Roger Heroux, Partner, Hospitalist Management Resources, LLC, 5490 Creighton Ct., Colorado Springs, CO 80918, 719/331-7119, or [email protected]. Visit the Society of Hospital Medicine Web site (www.hospitalmedicine.org) for information on practice management courses and other educational resources, including audiotapes of “Best Practices in Managing a Hospital Medicine Program.” TH

Larry Beresford is a regular contributor to The Hospitalist.

Many primary care physicians welcome the introduction of hospital medicine for its potential to help normalize their schedules, reduce interruptions to their clinic work from hospitalized patients, and moderate after-hours on-call demands. Some have found hospital medicine itself such an attractive option for balancing their schedules between work and personal commitments that they have pursued it as a career.

Internist Doyle Detweiler, MD, started closing down his medical office practice in Newton, Kan., a small town 15 miles north of Wichita, in June of this year so he could become the first full-time hospitalist at 81-bed Newton Medical Center. Pulled between his office practice and the demands of visiting his patients at the hospital, Dr. Detweiler had seen his family life suffer, with limited quality time to spend with his daughters Lilly, 4, and Hannah, 18 months.

“The worst thing was that when I’d go to work, I’d kiss my little girls goodbye and they’d still be bed. When I’d come home and kiss them good night, they’d already be in bed,” he says. “My wife would never know even approximately when I’d be heading home. So it would be difficult for us to plan anything in the evenings.” He also spent a lot of time working on the weekends.

Dr. Detweiler still faces significant time demands in his new job—at least until a second hospitalist can be brought on board later this year. But the move has already produced dividends in terms of shorter and more predictable hours. Generally, he wraps up work shortly after 6 p.m., when the last post-operative case has been admitted, and he has been called back to the hospital only three times in two months for after-hours patient crises.

“One big advantage I can see—once we ultimately get the program rolling—is that I’ll know when I’ll be working and when I’m off and checked out,” he explains. “As a hospitalist, there still will be times when I’m really busy, but it will be easier to plan something like going out for dinner at 7 p.m.”

The Needs of Children—and Parents

The classic juggle of work and home life involves the care of young children, although that is only one of the competing personal demands on doctors’ time. As the proportion of women in medicine has grown, employers have been challenged to find ways to accommodate their staffs’ maternity leaves and child-care responsibilities, while working parents seek to accommodate their children’s swimming lessons, ball games, and ballet classes.

The generation that now dominates hospitalist ranks (average age 37, according to SHM’s “Biannual Survey of the Hospital Medicine Movement”) has little taste for the traditional image of the old-fashioned, male family doctor, essentially available to his patients 24/7. Lifestyle issues are important factors in their career choices.

Other working hospitalists want time to travel or to pursue outside interests. Their hours of work may be shorter and more predictable than for other physicians, but the pace can be intense, with life-and-death situations involving critically ill patients occurring every day. Many of today’s hospitalists also belong to the “sandwich generation,” juggling simultaneous caregiving responsibilities for children and aging parents.

Stacy Walton Goldsholl, MD, of Wilmington, N.C., president of the hospital medicine division of TeamHealth, and member of the SHM Board of Directors, faced an extreme version of these competing demands when starting her new managerial position on January 1, 2006. Pregnant with her second child, Richard, who was born in April, she was also caring for her 65-year-old father, who died of cancer in February.

“It was tough watching my dad, formerly a very robust person, truly the motivating force for my professional success, my moral compass, confidant, and advisor, as he got sicker,” says Dr. Goldsholl. “Some days I’d leave my two-year-old, Aiden, with my husband and go care for my dad, giving him his injection of Lovenox [enoxaparin] or replacing his PCA pump. My mom and I were his primary caregivers at home until we physically couldn’t handle it.”

At that point her father was admitted to a hospice inpatient facility, where she would sit by his bedside with a computer in her lap.

Dr. Goldsholl probably would have needed to take a leave of absence if she had been working as a hospitalist, but her new employers at TeamHealth gave her a lot of flexibility, limiting the number of strategic meetings she had to attend. In general, however, she believes hospitalist shift work is more accommodating to family demands than an administrative position. She returned from maternity leave full time on June 1 and now travels every week for her job; her mother, who lives nearby, fills in as her grandchildren’s nanny. But Dr. Goldsholl’s experience has sparked her interest in exploring sustainability issues for other hospitalists.

“TeamHealth’s leaders told me their turnover rate is about 5 percent for hospitalists, versus an industry average of 19 percent,” says Dr. Goldsholl. “I found that hard to believe, but when I interviewed some of our local medical directors, it turned out to be true. They were all extremely positive about their relationship with our operational infrastructure.

“There’s so much to do and so many opportunities out there, but it must be sustainable,” she continues. “In order to sustain a career, you must be fulfilled personally, which is directly related to your work/life balance.”

When she drilled down into the company’s data, trying to find out why TeamHealth is able to retain its doctors, she found that the hours they work average 7.3% less than the industry as a whole, while their compensation is comparable to others.1

For Daniel Dressler, MD, medical director of the Hospital Medicine Group at Emory Healthcare in Atlanta, Ga., hospital medicine can be a juggling act—as can his committee work for SHM—although he is able to conduct some business from home. “When we do the conference calls for SHM, half of the time I’m home taking care of our kids”—one-year-old twins—often with one of them in his lap.

Dr. Dressler and his wife had been building a new home and working closely with contractors and subcontractors when she discovered she was pregnant last year. The construction project experienced multiple delays. When interviewed in September, the Dresslers were living temporarily with his in-laws and hoping the house would be completed within another month. His wife, a physical therapist, was not working but was looking forward to returning to work.

Dr. Dressler estimates that he puts in a 60-hour workweek, including 30 hours of hospitalist shifts and the rest administrative, teaching, and education. “I don’t recommend building a new house and having kids at the same time,” he says. “Taking care of one-year-old twins is more difficult than anything I do at work. But we have a good time.”

He also tries to squeeze in a basketball game with the medical residents every weekend.

Dr. Dressler’s schedule demands reflect an additional wrinkle in terms of juggling work and family—especially in a relatively new field with huge growth opportunities and an emphasis on changing the healthcare system. Doctors must balance what is truly required to perform the job and satisfy their employers with what they do to satisfy their own standards and expectations, as well as take advantage of opportunities to advance their careers.

“There’s the balance of what’s reasonable for you at this point in your career. It’s a personal decision for everyone—[deciding] what is an adequate amount of time for each of the priorities in your life … what drives you, and what makes you happy in your life,” says Dr. Dressler. “The things that drive me include teaching and advancing the field, which means seizing opportunities to grow with this new and growing field, but hopefully not to the detriment of the rest of my life.”

A Family-Friendly Practice

Arpana Vidyarthi, MD, an academic hospitalist at the University of California-San Francisco (UCSF), has responsibilities for teaching residents and medical students and additional roles in hospital quality and safety. “It’s a somewhat different role than a shift hospitalist, with different stressors,” she says. “But there are many options out there, and one of the things that makes being a hospitalist attractive to me is the flexibility it offers.”

Dr. Vidyarthi’s husband also has a demanding job. She is able to do some of her own work at home with her two-year-old daughter, Anaiya, but estimates that her nanny puts in a 50-hour week. “I came to UCSF to do a hospitalist fellowship, and this is exactly what I want to do, with tremendous job satisfaction and a varied schedule. Yet I feel stretched all the time,” she says.

Dr. Vidyarthi credits her group practice at UCSF and its head, Robert Wachter, MD, for a supportive and family-friendly working environment. Colleague Adrienne Green, MD, agrees, adding that three of the group’s 24 physician members are pregnant at this time.

Dr. Green’s children are very interested in her work and have visited her at the hospital, which makes the work more real to them. “I’ll tell them about some of my patients who are really sick, and I’ll explain that the reason I’m going to work on the weekend is that I’m helping people get better and get out of the hospital,” says Dr. Green. “When I’m working on a Saturday and my son has a baseball game, I’ll tell him I’ll try to get to the game, but I can’t promise. But when we do have family time, we make it quality time.”

Dr. Wachter explains how he promotes a family-friendly work environment for hospitalists at UCSF: “My overarching management philosophy is that the quality of our program is equal to the quality of the people we’re able to recruit and retain. Thus, an environment that is professionally satisfying, collegiate, fun, and supportive of everyone’s personal and family goals is fundamental.”

Balancing life and work requires some give and take among the members of the group, who cover for each other when needed. It also takes a commitment to staffing in anticipation of predictable future needs for maternity leaves, sabbaticals and the like, rather than waiting for the actual need to arrive.

Making Good Career Choices

Lisa Kettering, MD, a member of SHM’s Board of Directors, has been a working hospitalist since 1998. Before that she worked in a traditional internal medicine practice. She also believes that hospital medicine offers more flexibility and opportunities for balance, with a full-time hospitalist position roughly comparable to the “part-time” private practice position she once held.

“In private practice, you’re always coming back to phone calls and piles of charts,” says Dr. Kettering. “As a hospitalist, you take care of your business in real time, instead of always playing catch up.”

A year ago, Dr. Kettering assumed medical direction of a practice of nine hospitalists and three intensivists at Exempla-St. Joseph Hospital in Denver, Colo., a position that includes significant clinical duties and requires about 80 hours of her time per week.

“If my children [three sons age 21, 19, and 16] were not almost grown, I could not have accepted this position,” she says. “But this job is my passion. For me, the key to family balance has been a supportive spouse and lots of child care and other supports.”

Dr. Kettering’s sons were born just before or during her medical school and residency, so her long hours have always been part of the equation. “What I gave up [for this career] were aspects of a social life, such as dinners out with our friends and an opportunity to work on my tennis game” and similar hobbies, she says. She has continued to run, a time-efficient form of exercise and stress management. Now that her children are leaving home, there is more time to indulge a love of yoga and Pilates and to resume a more normal social life—although she doesn’t do much cooking.

Don’t be shy about getting help, Dr. Kettering advises. She engages a personal assistant eight hours a week to help with errands such as making travel arrangements, picking up groceries, taking the car in for servicing, or wrapping the birthday presents she buys. “Not that I couldn’t squeeze in a few errands on the way home from work, but it would just be more demands on my time,” she explains.

“I believe I am an optimist, but my advice to young doctors is this: Don’t believe you can do it all,” says Dr. Kettering. “You need to make careful, considered decisions along the way, understanding you do have control over your choices. But there’s no question that you’ll have to give up many things if you choose medicine as a career.”

The biggest recommendation Dr. Kettering offers for future hospitalists is to make career choices based on a passion for the work—not on the flexible hours. Then consider how to make the job work in terms of schedules and the other nuts and bolts of practice, being aware of the varied opportunities that exist.

Although hospital medicine is sometimes described as a young person’s game, Dr. Kettering believes that if it is practiced correctly, with a sustainable work schedule, it doesn’t have to lead to burnout or exhaustion. “My practice is [composed] exclusively of doctors who have chosen hospital medicine as a life’s work—not a stopgap between residency and fellowship,” she says. “We also have a wonderful group of physicians, and there has not been a time when somebody had a family emergency that somebody else didn’t step up to cover.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

Reference

1. Compensation by Employment Model, Society of Hospital Medicine Benchmark Survey, 2003.

Many primary care physicians welcome the introduction of hospital medicine for its potential to help normalize their schedules, reduce interruptions to their clinic work from hospitalized patients, and moderate after-hours on-call demands. Some have found hospital medicine itself such an attractive option for balancing their schedules between work and personal commitments that they have pursued it as a career.

Internist Doyle Detweiler, MD, started closing down his medical office practice in Newton, Kan., a small town 15 miles north of Wichita, in June of this year so he could become the first full-time hospitalist at 81-bed Newton Medical Center. Pulled between his office practice and the demands of visiting his patients at the hospital, Dr. Detweiler had seen his family life suffer, with limited quality time to spend with his daughters Lilly, 4, and Hannah, 18 months.

“The worst thing was that when I’d go to work, I’d kiss my little girls goodbye and they’d still be bed. When I’d come home and kiss them good night, they’d already be in bed,” he says. “My wife would never know even approximately when I’d be heading home. So it would be difficult for us to plan anything in the evenings.” He also spent a lot of time working on the weekends.

Dr. Detweiler still faces significant time demands in his new job—at least until a second hospitalist can be brought on board later this year. But the move has already produced dividends in terms of shorter and more predictable hours. Generally, he wraps up work shortly after 6 p.m., when the last post-operative case has been admitted, and he has been called back to the hospital only three times in two months for after-hours patient crises.

“One big advantage I can see—once we ultimately get the program rolling—is that I’ll know when I’ll be working and when I’m off and checked out,” he explains. “As a hospitalist, there still will be times when I’m really busy, but it will be easier to plan something like going out for dinner at 7 p.m.”

The Needs of Children—and Parents

The classic juggle of work and home life involves the care of young children, although that is only one of the competing personal demands on doctors’ time. As the proportion of women in medicine has grown, employers have been challenged to find ways to accommodate their staffs’ maternity leaves and child-care responsibilities, while working parents seek to accommodate their children’s swimming lessons, ball games, and ballet classes.

The generation that now dominates hospitalist ranks (average age 37, according to SHM’s “Biannual Survey of the Hospital Medicine Movement”) has little taste for the traditional image of the old-fashioned, male family doctor, essentially available to his patients 24/7. Lifestyle issues are important factors in their career choices.

Other working hospitalists want time to travel or to pursue outside interests. Their hours of work may be shorter and more predictable than for other physicians, but the pace can be intense, with life-and-death situations involving critically ill patients occurring every day. Many of today’s hospitalists also belong to the “sandwich generation,” juggling simultaneous caregiving responsibilities for children and aging parents.

Stacy Walton Goldsholl, MD, of Wilmington, N.C., president of the hospital medicine division of TeamHealth, and member of the SHM Board of Directors, faced an extreme version of these competing demands when starting her new managerial position on January 1, 2006. Pregnant with her second child, Richard, who was born in April, she was also caring for her 65-year-old father, who died of cancer in February.

“It was tough watching my dad, formerly a very robust person, truly the motivating force for my professional success, my moral compass, confidant, and advisor, as he got sicker,” says Dr. Goldsholl. “Some days I’d leave my two-year-old, Aiden, with my husband and go care for my dad, giving him his injection of Lovenox [enoxaparin] or replacing his PCA pump. My mom and I were his primary caregivers at home until we physically couldn’t handle it.”

At that point her father was admitted to a hospice inpatient facility, where she would sit by his bedside with a computer in her lap.

Dr. Goldsholl probably would have needed to take a leave of absence if she had been working as a hospitalist, but her new employers at TeamHealth gave her a lot of flexibility, limiting the number of strategic meetings she had to attend. In general, however, she believes hospitalist shift work is more accommodating to family demands than an administrative position. She returned from maternity leave full time on June 1 and now travels every week for her job; her mother, who lives nearby, fills in as her grandchildren’s nanny. But Dr. Goldsholl’s experience has sparked her interest in exploring sustainability issues for other hospitalists.

“TeamHealth’s leaders told me their turnover rate is about 5 percent for hospitalists, versus an industry average of 19 percent,” says Dr. Goldsholl. “I found that hard to believe, but when I interviewed some of our local medical directors, it turned out to be true. They were all extremely positive about their relationship with our operational infrastructure.

“There’s so much to do and so many opportunities out there, but it must be sustainable,” she continues. “In order to sustain a career, you must be fulfilled personally, which is directly related to your work/life balance.”

When she drilled down into the company’s data, trying to find out why TeamHealth is able to retain its doctors, she found that the hours they work average 7.3% less than the industry as a whole, while their compensation is comparable to others.1

For Daniel Dressler, MD, medical director of the Hospital Medicine Group at Emory Healthcare in Atlanta, Ga., hospital medicine can be a juggling act—as can his committee work for SHM—although he is able to conduct some business from home. “When we do the conference calls for SHM, half of the time I’m home taking care of our kids”—one-year-old twins—often with one of them in his lap.

Dr. Dressler and his wife had been building a new home and working closely with contractors and subcontractors when she discovered she was pregnant last year. The construction project experienced multiple delays. When interviewed in September, the Dresslers were living temporarily with his in-laws and hoping the house would be completed within another month. His wife, a physical therapist, was not working but was looking forward to returning to work.

Dr. Dressler estimates that he puts in a 60-hour workweek, including 30 hours of hospitalist shifts and the rest administrative, teaching, and education. “I don’t recommend building a new house and having kids at the same time,” he says. “Taking care of one-year-old twins is more difficult than anything I do at work. But we have a good time.”

He also tries to squeeze in a basketball game with the medical residents every weekend.

Dr. Dressler’s schedule demands reflect an additional wrinkle in terms of juggling work and family—especially in a relatively new field with huge growth opportunities and an emphasis on changing the healthcare system. Doctors must balance what is truly required to perform the job and satisfy their employers with what they do to satisfy their own standards and expectations, as well as take advantage of opportunities to advance their careers.

“There’s the balance of what’s reasonable for you at this point in your career. It’s a personal decision for everyone—[deciding] what is an adequate amount of time for each of the priorities in your life … what drives you, and what makes you happy in your life,” says Dr. Dressler. “The things that drive me include teaching and advancing the field, which means seizing opportunities to grow with this new and growing field, but hopefully not to the detriment of the rest of my life.”

A Family-Friendly Practice

Arpana Vidyarthi, MD, an academic hospitalist at the University of California-San Francisco (UCSF), has responsibilities for teaching residents and medical students and additional roles in hospital quality and safety. “It’s a somewhat different role than a shift hospitalist, with different stressors,” she says. “But there are many options out there, and one of the things that makes being a hospitalist attractive to me is the flexibility it offers.”

Dr. Vidyarthi’s husband also has a demanding job. She is able to do some of her own work at home with her two-year-old daughter, Anaiya, but estimates that her nanny puts in a 50-hour week. “I came to UCSF to do a hospitalist fellowship, and this is exactly what I want to do, with tremendous job satisfaction and a varied schedule. Yet I feel stretched all the time,” she says.

Dr. Vidyarthi credits her group practice at UCSF and its head, Robert Wachter, MD, for a supportive and family-friendly working environment. Colleague Adrienne Green, MD, agrees, adding that three of the group’s 24 physician members are pregnant at this time.

Dr. Green’s children are very interested in her work and have visited her at the hospital, which makes the work more real to them. “I’ll tell them about some of my patients who are really sick, and I’ll explain that the reason I’m going to work on the weekend is that I’m helping people get better and get out of the hospital,” says Dr. Green. “When I’m working on a Saturday and my son has a baseball game, I’ll tell him I’ll try to get to the game, but I can’t promise. But when we do have family time, we make it quality time.”

Dr. Wachter explains how he promotes a family-friendly work environment for hospitalists at UCSF: “My overarching management philosophy is that the quality of our program is equal to the quality of the people we’re able to recruit and retain. Thus, an environment that is professionally satisfying, collegiate, fun, and supportive of everyone’s personal and family goals is fundamental.”

Balancing life and work requires some give and take among the members of the group, who cover for each other when needed. It also takes a commitment to staffing in anticipation of predictable future needs for maternity leaves, sabbaticals and the like, rather than waiting for the actual need to arrive.

Making Good Career Choices

Lisa Kettering, MD, a member of SHM’s Board of Directors, has been a working hospitalist since 1998. Before that she worked in a traditional internal medicine practice. She also believes that hospital medicine offers more flexibility and opportunities for balance, with a full-time hospitalist position roughly comparable to the “part-time” private practice position she once held.

“In private practice, you’re always coming back to phone calls and piles of charts,” says Dr. Kettering. “As a hospitalist, you take care of your business in real time, instead of always playing catch up.”

A year ago, Dr. Kettering assumed medical direction of a practice of nine hospitalists and three intensivists at Exempla-St. Joseph Hospital in Denver, Colo., a position that includes significant clinical duties and requires about 80 hours of her time per week.

“If my children [three sons age 21, 19, and 16] were not almost grown, I could not have accepted this position,” she says. “But this job is my passion. For me, the key to family balance has been a supportive spouse and lots of child care and other supports.”

Dr. Kettering’s sons were born just before or during her medical school and residency, so her long hours have always been part of the equation. “What I gave up [for this career] were aspects of a social life, such as dinners out with our friends and an opportunity to work on my tennis game” and similar hobbies, she says. She has continued to run, a time-efficient form of exercise and stress management. Now that her children are leaving home, there is more time to indulge a love of yoga and Pilates and to resume a more normal social life—although she doesn’t do much cooking.

Don’t be shy about getting help, Dr. Kettering advises. She engages a personal assistant eight hours a week to help with errands such as making travel arrangements, picking up groceries, taking the car in for servicing, or wrapping the birthday presents she buys. “Not that I couldn’t squeeze in a few errands on the way home from work, but it would just be more demands on my time,” she explains.

“I believe I am an optimist, but my advice to young doctors is this: Don’t believe you can do it all,” says Dr. Kettering. “You need to make careful, considered decisions along the way, understanding you do have control over your choices. But there’s no question that you’ll have to give up many things if you choose medicine as a career.”

The biggest recommendation Dr. Kettering offers for future hospitalists is to make career choices based on a passion for the work—not on the flexible hours. Then consider how to make the job work in terms of schedules and the other nuts and bolts of practice, being aware of the varied opportunities that exist.

Although hospital medicine is sometimes described as a young person’s game, Dr. Kettering believes that if it is practiced correctly, with a sustainable work schedule, it doesn’t have to lead to burnout or exhaustion. “My practice is [composed] exclusively of doctors who have chosen hospital medicine as a life’s work—not a stopgap between residency and fellowship,” she says. “We also have a wonderful group of physicians, and there has not been a time when somebody had a family emergency that somebody else didn’t step up to cover.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

Reference

1. Compensation by Employment Model, Society of Hospital Medicine Benchmark Survey, 2003.

Many primary care physicians welcome the introduction of hospital medicine for its potential to help normalize their schedules, reduce interruptions to their clinic work from hospitalized patients, and moderate after-hours on-call demands. Some have found hospital medicine itself such an attractive option for balancing their schedules between work and personal commitments that they have pursued it as a career.

Internist Doyle Detweiler, MD, started closing down his medical office practice in Newton, Kan., a small town 15 miles north of Wichita, in June of this year so he could become the first full-time hospitalist at 81-bed Newton Medical Center. Pulled between his office practice and the demands of visiting his patients at the hospital, Dr. Detweiler had seen his family life suffer, with limited quality time to spend with his daughters Lilly, 4, and Hannah, 18 months.

“The worst thing was that when I’d go to work, I’d kiss my little girls goodbye and they’d still be bed. When I’d come home and kiss them good night, they’d already be in bed,” he says. “My wife would never know even approximately when I’d be heading home. So it would be difficult for us to plan anything in the evenings.” He also spent a lot of time working on the weekends.

Dr. Detweiler still faces significant time demands in his new job—at least until a second hospitalist can be brought on board later this year. But the move has already produced dividends in terms of shorter and more predictable hours. Generally, he wraps up work shortly after 6 p.m., when the last post-operative case has been admitted, and he has been called back to the hospital only three times in two months for after-hours patient crises.

“One big advantage I can see—once we ultimately get the program rolling—is that I’ll know when I’ll be working and when I’m off and checked out,” he explains. “As a hospitalist, there still will be times when I’m really busy, but it will be easier to plan something like going out for dinner at 7 p.m.”

The Needs of Children—and Parents

The classic juggle of work and home life involves the care of young children, although that is only one of the competing personal demands on doctors’ time. As the proportion of women in medicine has grown, employers have been challenged to find ways to accommodate their staffs’ maternity leaves and child-care responsibilities, while working parents seek to accommodate their children’s swimming lessons, ball games, and ballet classes.

The generation that now dominates hospitalist ranks (average age 37, according to SHM’s “Biannual Survey of the Hospital Medicine Movement”) has little taste for the traditional image of the old-fashioned, male family doctor, essentially available to his patients 24/7. Lifestyle issues are important factors in their career choices.

Other working hospitalists want time to travel or to pursue outside interests. Their hours of work may be shorter and more predictable than for other physicians, but the pace can be intense, with life-and-death situations involving critically ill patients occurring every day. Many of today’s hospitalists also belong to the “sandwich generation,” juggling simultaneous caregiving responsibilities for children and aging parents.

Stacy Walton Goldsholl, MD, of Wilmington, N.C., president of the hospital medicine division of TeamHealth, and member of the SHM Board of Directors, faced an extreme version of these competing demands when starting her new managerial position on January 1, 2006. Pregnant with her second child, Richard, who was born in April, she was also caring for her 65-year-old father, who died of cancer in February.

“It was tough watching my dad, formerly a very robust person, truly the motivating force for my professional success, my moral compass, confidant, and advisor, as he got sicker,” says Dr. Goldsholl. “Some days I’d leave my two-year-old, Aiden, with my husband and go care for my dad, giving him his injection of Lovenox [enoxaparin] or replacing his PCA pump. My mom and I were his primary caregivers at home until we physically couldn’t handle it.”

At that point her father was admitted to a hospice inpatient facility, where she would sit by his bedside with a computer in her lap.

Dr. Goldsholl probably would have needed to take a leave of absence if she had been working as a hospitalist, but her new employers at TeamHealth gave her a lot of flexibility, limiting the number of strategic meetings she had to attend. In general, however, she believes hospitalist shift work is more accommodating to family demands than an administrative position. She returned from maternity leave full time on June 1 and now travels every week for her job; her mother, who lives nearby, fills in as her grandchildren’s nanny. But Dr. Goldsholl’s experience has sparked her interest in exploring sustainability issues for other hospitalists.

“TeamHealth’s leaders told me their turnover rate is about 5 percent for hospitalists, versus an industry average of 19 percent,” says Dr. Goldsholl. “I found that hard to believe, but when I interviewed some of our local medical directors, it turned out to be true. They were all extremely positive about their relationship with our operational infrastructure.

“There’s so much to do and so many opportunities out there, but it must be sustainable,” she continues. “In order to sustain a career, you must be fulfilled personally, which is directly related to your work/life balance.”

When she drilled down into the company’s data, trying to find out why TeamHealth is able to retain its doctors, she found that the hours they work average 7.3% less than the industry as a whole, while their compensation is comparable to others.1

For Daniel Dressler, MD, medical director of the Hospital Medicine Group at Emory Healthcare in Atlanta, Ga., hospital medicine can be a juggling act—as can his committee work for SHM—although he is able to conduct some business from home. “When we do the conference calls for SHM, half of the time I’m home taking care of our kids”—one-year-old twins—often with one of them in his lap.

Dr. Dressler and his wife had been building a new home and working closely with contractors and subcontractors when she discovered she was pregnant last year. The construction project experienced multiple delays. When interviewed in September, the Dresslers were living temporarily with his in-laws and hoping the house would be completed within another month. His wife, a physical therapist, was not working but was looking forward to returning to work.

Dr. Dressler estimates that he puts in a 60-hour workweek, including 30 hours of hospitalist shifts and the rest administrative, teaching, and education. “I don’t recommend building a new house and having kids at the same time,” he says. “Taking care of one-year-old twins is more difficult than anything I do at work. But we have a good time.”

He also tries to squeeze in a basketball game with the medical residents every weekend.

Dr. Dressler’s schedule demands reflect an additional wrinkle in terms of juggling work and family—especially in a relatively new field with huge growth opportunities and an emphasis on changing the healthcare system. Doctors must balance what is truly required to perform the job and satisfy their employers with what they do to satisfy their own standards and expectations, as well as take advantage of opportunities to advance their careers.

“There’s the balance of what’s reasonable for you at this point in your career. It’s a personal decision for everyone—[deciding] what is an adequate amount of time for each of the priorities in your life … what drives you, and what makes you happy in your life,” says Dr. Dressler. “The things that drive me include teaching and advancing the field, which means seizing opportunities to grow with this new and growing field, but hopefully not to the detriment of the rest of my life.”

A Family-Friendly Practice

Arpana Vidyarthi, MD, an academic hospitalist at the University of California-San Francisco (UCSF), has responsibilities for teaching residents and medical students and additional roles in hospital quality and safety. “It’s a somewhat different role than a shift hospitalist, with different stressors,” she says. “But there are many options out there, and one of the things that makes being a hospitalist attractive to me is the flexibility it offers.”

Dr. Vidyarthi’s husband also has a demanding job. She is able to do some of her own work at home with her two-year-old daughter, Anaiya, but estimates that her nanny puts in a 50-hour week. “I came to UCSF to do a hospitalist fellowship, and this is exactly what I want to do, with tremendous job satisfaction and a varied schedule. Yet I feel stretched all the time,” she says.

Dr. Vidyarthi credits her group practice at UCSF and its head, Robert Wachter, MD, for a supportive and family-friendly working environment. Colleague Adrienne Green, MD, agrees, adding that three of the group’s 24 physician members are pregnant at this time.

Dr. Green’s children are very interested in her work and have visited her at the hospital, which makes the work more real to them. “I’ll tell them about some of my patients who are really sick, and I’ll explain that the reason I’m going to work on the weekend is that I’m helping people get better and get out of the hospital,” says Dr. Green. “When I’m working on a Saturday and my son has a baseball game, I’ll tell him I’ll try to get to the game, but I can’t promise. But when we do have family time, we make it quality time.”

Dr. Wachter explains how he promotes a family-friendly work environment for hospitalists at UCSF: “My overarching management philosophy is that the quality of our program is equal to the quality of the people we’re able to recruit and retain. Thus, an environment that is professionally satisfying, collegiate, fun, and supportive of everyone’s personal and family goals is fundamental.”

Balancing life and work requires some give and take among the members of the group, who cover for each other when needed. It also takes a commitment to staffing in anticipation of predictable future needs for maternity leaves, sabbaticals and the like, rather than waiting for the actual need to arrive.

Making Good Career Choices

Lisa Kettering, MD, a member of SHM’s Board of Directors, has been a working hospitalist since 1998. Before that she worked in a traditional internal medicine practice. She also believes that hospital medicine offers more flexibility and opportunities for balance, with a full-time hospitalist position roughly comparable to the “part-time” private practice position she once held.

“In private practice, you’re always coming back to phone calls and piles of charts,” says Dr. Kettering. “As a hospitalist, you take care of your business in real time, instead of always playing catch up.”

A year ago, Dr. Kettering assumed medical direction of a practice of nine hospitalists and three intensivists at Exempla-St. Joseph Hospital in Denver, Colo., a position that includes significant clinical duties and requires about 80 hours of her time per week.

“If my children [three sons age 21, 19, and 16] were not almost grown, I could not have accepted this position,” she says. “But this job is my passion. For me, the key to family balance has been a supportive spouse and lots of child care and other supports.”

Dr. Kettering’s sons were born just before or during her medical school and residency, so her long hours have always been part of the equation. “What I gave up [for this career] were aspects of a social life, such as dinners out with our friends and an opportunity to work on my tennis game” and similar hobbies, she says. She has continued to run, a time-efficient form of exercise and stress management. Now that her children are leaving home, there is more time to indulge a love of yoga and Pilates and to resume a more normal social life—although she doesn’t do much cooking.

Don’t be shy about getting help, Dr. Kettering advises. She engages a personal assistant eight hours a week to help with errands such as making travel arrangements, picking up groceries, taking the car in for servicing, or wrapping the birthday presents she buys. “Not that I couldn’t squeeze in a few errands on the way home from work, but it would just be more demands on my time,” she explains.

“I believe I am an optimist, but my advice to young doctors is this: Don’t believe you can do it all,” says Dr. Kettering. “You need to make careful, considered decisions along the way, understanding you do have control over your choices. But there’s no question that you’ll have to give up many things if you choose medicine as a career.”

The biggest recommendation Dr. Kettering offers for future hospitalists is to make career choices based on a passion for the work—not on the flexible hours. Then consider how to make the job work in terms of schedules and the other nuts and bolts of practice, being aware of the varied opportunities that exist.

Although hospital medicine is sometimes described as a young person’s game, Dr. Kettering believes that if it is practiced correctly, with a sustainable work schedule, it doesn’t have to lead to burnout or exhaustion. “My practice is [composed] exclusively of doctors who have chosen hospital medicine as a life’s work—not a stopgap between residency and fellowship,” she says. “We also have a wonderful group of physicians, and there has not been a time when somebody had a family emergency that somebody else didn’t step up to cover.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

Reference

1. Compensation by Employment Model, Society of Hospital Medicine Benchmark Survey, 2003.

When Karie Praszek, MD, a hospitalist at the University of Texas Health Center at Tyler (UTHCT) found out this past fall that she was being considered for the position of medical director of the hospital’s planned hospice inpatient unit, she went home after work and cried. These were tears of happiness because she was finally going to be able to combine her two loves as a physician: hospital medicine and hospice care. “It was like coming full circle,” she explains.

The seven-bed hospice unit at UTHCT opened in partnership with Hospice of East Texas in Tyler in November, following renovations to create more comfortable and spacious rooms. It is one of a growing number of collaborations between hospitals and community hospice programs to provide institutional beds for terminally ill, hospice-enrolled patients in need of short-term inpatient care for symptom management.

In many hospitals, hospitalists are well positioned to provide planning, leadership, hospice referrals, or medical management of hospice units in the hospital. But few of them will follow a path like Dr. Praszek’s to the medical leadership of the hospice unit.

The Needs of End-of-Life Patients

Dr. Praszek’s commitment to the needs of patients facing the end of their lives took her from Texas to Oklahoma to Oregon and back to Texas. She has been a practicing hospitalist at UTHCT since 2004, but medicine wasn’t her first career. In the 1980s, as a computer expert for the U.S. Postal Service, she helped to automate postal facilities. She was well paid, she says, but something was missing in her life.

Wanting to make a meaningful contribution, Dr. Praszek became a volunteer candy striper at a hospital in Dallas. She learned about hospice while assigned to the oncology floor.

“When I started doing hospice care, I fell in love with it, and used volunteer work to hone my skills,” she says. She quit her job and moved to Oklahoma to attend a seminary with a specialized curriculum in death, dying, and grief counseling, all the while volunteering with hospice patients.

“They even trained me to be a certified nurse’s aide,” she says. “I just wanted to do whatever they needed—to do what no one else wanted to do.”

As a volunteer nurse’s aide she cleaned bedpans, changed diapers, and gave bed baths to hospice patients. “I didn’t mind it because it meant I could have more time to talk with the patients,” explains Dr. Praszek.

A turning point came while she was on a hospice wing of a nursing home, working with a patient who had metastatic prostate cancer and was in excruciating pain. “You could hear this gentleman moaning when you entered the building,” she recalls.

The nurses on the unit turned to Dr. Praszek and asked her to call the patient’s physician for an order for more pain medications. “I said, ‘I’m just a volunteer,’ but they told me, ‘You’re our last hope,’ ” recounts Dr. Praszek. “So I called the doctor, and he said he wouldn’t order any more pain medications because he didn’t want the terminally ill patient to become an addict. Then he said, ‘I’m the doctor and you’re not,’ and hung up on me. I thought, well, you so-and-so. I’ll go to medical school instead of nursing school, which I had been considering, so that nobody can ever pull this kind of thing on me again.”

Dr. Praszek completed her pre-med courses, but put off applying because she was afraid that she was too old or not smart enough. Finally, with her husband’s encouragement, she applied to Oregon Health Sciences University and, on her 40th birthday in 1996, received notification of acceptance. Looking for students with significant life experience, the medical school offered Dr. Praszek a full scholarship. She graduated at the head of her class.

After completing her internal medicine residency, she couldn’t find a hospice-related position, but she had learned to appreciate the pace and complexity of hospital medicine. After doing locum tenens (temporary assignments), she landed in the hospitalist position at UTHCT. The 100-bed facility began as a tuberculosis hospital housed in a former U.S. Army base in 1949, and in 1977 it became part of the University of Texas health system.

Today Dr. Praszek heads a three-person hospital medicine department, with another physician and a physician’s assistant and the backup of 10 clinic physicians for after-hours coverage. Her job combines both clinical and administrative responsibilities, including risk assessments, protocol development, and the ethics committee. Roughly 10% of her time is devoted to patients on the hospice unit.

Providing Necessary Care

Hospice is an approach to the care of patients with life-limiting illnesses and their families, emphasizing the relief of pain and other symptoms, maximizing quality of life and support for the emotional and spiritual issues that come up at this time of life. Under the Medicare Hospice Benefit (introduced in 1983) Medicare-certified hospice programs are responsible for providing essentially all of the care needed to manage their enrolled patients, who have a life expectancy of six months or less. Medicare pays the hospice a daily packaged rate for its services—all-inclusive except for attending or consulting physicians, who are able to bill separately. Although the hospice benefit is primarily intended as a service in the patient’s home or other place of residence, such as a nursing home, often terminally ill patients require inpatient care for short periods to bring their medical symptoms under control.

To fill this need, hospice programs can open their own freestanding inpatient facilities, as Hospice of East Texas did with its 28-bed HomePlace, or else contract with a hospital for inpatient beds, as the hospice did with UTHCT. Those involved in planning the hospice unit at UTHCT emphasize that at the rate Medicare pays for inpatient hospice care ($562.69 per day, regionally adjusted), neither partner is likely to derive a profit from it. Instead the unit reflects a true commitment by both to meeting the needs of terminally ill patients in the hospital.

“This hospice unit was the right thing to do,” says UTHCT’s Chief Medical Officer Steven Brown, MD. “It’s an opportunity to educate our medical staff about end-of-life care, introduce the concept of hospice into the hospital, and improve utilization,” by changing the focus of treatment for those who choose the hospice approach.

The unit also provides an opportunity to concentrate palliative care training for nurses on the floor, which includes neuro-restorative and tuberculosis beds as well as non-dedicated hospice beds. Many patients are simultaneously referred to the unit and to Hospice of East Texas, while others may receive hospice care at home at the time of their placement on the unit.

Bring Inpatient Care Closer to Families

Marjorie Ream, CEO of Hospice of East Texas, explains that the origins of the hospice unit at UTHCT are in response to her agency’s family satisfaction surveys. Some families in the northeastern corner of the agency’s 13-county service area said they drove too far to visit loved ones at its HomePlace inpatient facility.

“We looked at our mission statement and started to explore how to make inpatient care available closer to the folks we serve,” says Ream. “I started a dialogue with Dr. Kirk Calhoun, the hospital’s president.”

Coincidentally, Dr. Calhoun had attended a hospital conference where he learned about a collaboration between a public charity hospital and a hospice in Atlanta that had received recognition from the American Hospital Association.

Their first meeting to discuss collaborating was in August 2005, and by November 15 the renovated unit was in operation, with two-room suites large enough to allow the patient’s family members to stay overnight on pullout sofas. Dr. Praszek’s name entered the dialogue after she gave a hospital lecture on end-of-life care and code status. “When we talked with her and she shared her career journey, we could see that she was a logical fit,” explains Ream. “And she really wanted to do this.

“My impression is that Dr. Praszek has a true ‘hospice heart.’ She really understands the interdisciplinary team. She’s an expert clinician, and she understands the differences in treating terminally ill patients. She has a real sense of the patient and family as people,” says Ream. “Nurses love her commitment and enthusiasm and are proud to be her colleagues.”

Dr. Praszek’s first concern is keeping people healthy. “To be a hospitalist on a hospice unit, you have to know how to change your focus from cure to caring,” she says. “It takes someone who is not afraid of confronting their patients’—or their own—mortality. When we first opened the unit, there was a sharp learning curve for physicians in the hospital. But it’s been a pretty smooth transition overall, except for one or two who still have a hard time recognizing when their patient is dying. Most physicians at this institution are learning how to look at the entire lifespan of their patients.”

Dr. Praszek tries to see every patient on the hospice unit each day she is on service. She also works closely with the interdisciplinary team at Hospice of East Texas. Routine care on the unit is provided by hospital staff, while the hospice team provides care management and oversight. Hospice care generally involves fewer intensive medical procedures and more intensive nursing care and comfort measures.

A Deeper Commitment

“My life today is the way it is because I really love my work,” says Dr. Praszek. She brings a lot of it home at night. In fact, Dr. Brown says he occasionally worries about the long hours she works. “But we try to make sure she gets the support she needs.”

“My door is always open,” adds Dr. Praszek. “I’m still learning from the nurses, and I’ve had housekeeping staff give me advice. When they find out my background [as a nurse’s aide], they always say, ‘Oh, that’s why we get along so well.’ ” TH

Larry Beresford wrote about hospitalists who work as administrators in the July issue.

When Karie Praszek, MD, a hospitalist at the University of Texas Health Center at Tyler (UTHCT) found out this past fall that she was being considered for the position of medical director of the hospital’s planned hospice inpatient unit, she went home after work and cried. These were tears of happiness because she was finally going to be able to combine her two loves as a physician: hospital medicine and hospice care. “It was like coming full circle,” she explains.

The seven-bed hospice unit at UTHCT opened in partnership with Hospice of East Texas in Tyler in November, following renovations to create more comfortable and spacious rooms. It is one of a growing number of collaborations between hospitals and community hospice programs to provide institutional beds for terminally ill, hospice-enrolled patients in need of short-term inpatient care for symptom management.

In many hospitals, hospitalists are well positioned to provide planning, leadership, hospice referrals, or medical management of hospice units in the hospital. But few of them will follow a path like Dr. Praszek’s to the medical leadership of the hospice unit.

The Needs of End-of-Life Patients

Dr. Praszek’s commitment to the needs of patients facing the end of their lives took her from Texas to Oklahoma to Oregon and back to Texas. She has been a practicing hospitalist at UTHCT since 2004, but medicine wasn’t her first career. In the 1980s, as a computer expert for the U.S. Postal Service, she helped to automate postal facilities. She was well paid, she says, but something was missing in her life.

Wanting to make a meaningful contribution, Dr. Praszek became a volunteer candy striper at a hospital in Dallas. She learned about hospice while assigned to the oncology floor.

“When I started doing hospice care, I fell in love with it, and used volunteer work to hone my skills,” she says. She quit her job and moved to Oklahoma to attend a seminary with a specialized curriculum in death, dying, and grief counseling, all the while volunteering with hospice patients.

“They even trained me to be a certified nurse’s aide,” she says. “I just wanted to do whatever they needed—to do what no one else wanted to do.”

As a volunteer nurse’s aide she cleaned bedpans, changed diapers, and gave bed baths to hospice patients. “I didn’t mind it because it meant I could have more time to talk with the patients,” explains Dr. Praszek.

A turning point came while she was on a hospice wing of a nursing home, working with a patient who had metastatic prostate cancer and was in excruciating pain. “You could hear this gentleman moaning when you entered the building,” she recalls.

The nurses on the unit turned to Dr. Praszek and asked her to call the patient’s physician for an order for more pain medications. “I said, ‘I’m just a volunteer,’ but they told me, ‘You’re our last hope,’ ” recounts Dr. Praszek. “So I called the doctor, and he said he wouldn’t order any more pain medications because he didn’t want the terminally ill patient to become an addict. Then he said, ‘I’m the doctor and you’re not,’ and hung up on me. I thought, well, you so-and-so. I’ll go to medical school instead of nursing school, which I had been considering, so that nobody can ever pull this kind of thing on me again.”

Dr. Praszek completed her pre-med courses, but put off applying because she was afraid that she was too old or not smart enough. Finally, with her husband’s encouragement, she applied to Oregon Health Sciences University and, on her 40th birthday in 1996, received notification of acceptance. Looking for students with significant life experience, the medical school offered Dr. Praszek a full scholarship. She graduated at the head of her class.

After completing her internal medicine residency, she couldn’t find a hospice-related position, but she had learned to appreciate the pace and complexity of hospital medicine. After doing locum tenens (temporary assignments), she landed in the hospitalist position at UTHCT. The 100-bed facility began as a tuberculosis hospital housed in a former U.S. Army base in 1949, and in 1977 it became part of the University of Texas health system.

Today Dr. Praszek heads a three-person hospital medicine department, with another physician and a physician’s assistant and the backup of 10 clinic physicians for after-hours coverage. Her job combines both clinical and administrative responsibilities, including risk assessments, protocol development, and the ethics committee. Roughly 10% of her time is devoted to patients on the hospice unit.

Providing Necessary Care

Hospice is an approach to the care of patients with life-limiting illnesses and their families, emphasizing the relief of pain and other symptoms, maximizing quality of life and support for the emotional and spiritual issues that come up at this time of life. Under the Medicare Hospice Benefit (introduced in 1983) Medicare-certified hospice programs are responsible for providing essentially all of the care needed to manage their enrolled patients, who have a life expectancy of six months or less. Medicare pays the hospice a daily packaged rate for its services—all-inclusive except for attending or consulting physicians, who are able to bill separately. Although the hospice benefit is primarily intended as a service in the patient’s home or other place of residence, such as a nursing home, often terminally ill patients require inpatient care for short periods to bring their medical symptoms under control.

To fill this need, hospice programs can open their own freestanding inpatient facilities, as Hospice of East Texas did with its 28-bed HomePlace, or else contract with a hospital for inpatient beds, as the hospice did with UTHCT. Those involved in planning the hospice unit at UTHCT emphasize that at the rate Medicare pays for inpatient hospice care ($562.69 per day, regionally adjusted), neither partner is likely to derive a profit from it. Instead the unit reflects a true commitment by both to meeting the needs of terminally ill patients in the hospital.

“This hospice unit was the right thing to do,” says UTHCT’s Chief Medical Officer Steven Brown, MD. “It’s an opportunity to educate our medical staff about end-of-life care, introduce the concept of hospice into the hospital, and improve utilization,” by changing the focus of treatment for those who choose the hospice approach.

The unit also provides an opportunity to concentrate palliative care training for nurses on the floor, which includes neuro-restorative and tuberculosis beds as well as non-dedicated hospice beds. Many patients are simultaneously referred to the unit and to Hospice of East Texas, while others may receive hospice care at home at the time of their placement on the unit.

Bring Inpatient Care Closer to Families

Marjorie Ream, CEO of Hospice of East Texas, explains that the origins of the hospice unit at UTHCT are in response to her agency’s family satisfaction surveys. Some families in the northeastern corner of the agency’s 13-county service area said they drove too far to visit loved ones at its HomePlace inpatient facility.

“We looked at our mission statement and started to explore how to make inpatient care available closer to the folks we serve,” says Ream. “I started a dialogue with Dr. Kirk Calhoun, the hospital’s president.”

Coincidentally, Dr. Calhoun had attended a hospital conference where he learned about a collaboration between a public charity hospital and a hospice in Atlanta that had received recognition from the American Hospital Association.

Their first meeting to discuss collaborating was in August 2005, and by November 15 the renovated unit was in operation, with two-room suites large enough to allow the patient’s family members to stay overnight on pullout sofas. Dr. Praszek’s name entered the dialogue after she gave a hospital lecture on end-of-life care and code status. “When we talked with her and she shared her career journey, we could see that she was a logical fit,” explains Ream. “And she really wanted to do this.

“My impression is that Dr. Praszek has a true ‘hospice heart.’ She really understands the interdisciplinary team. She’s an expert clinician, and she understands the differences in treating terminally ill patients. She has a real sense of the patient and family as people,” says Ream. “Nurses love her commitment and enthusiasm and are proud to be her colleagues.”

Dr. Praszek’s first concern is keeping people healthy. “To be a hospitalist on a hospice unit, you have to know how to change your focus from cure to caring,” she says. “It takes someone who is not afraid of confronting their patients’—or their own—mortality. When we first opened the unit, there was a sharp learning curve for physicians in the hospital. But it’s been a pretty smooth transition overall, except for one or two who still have a hard time recognizing when their patient is dying. Most physicians at this institution are learning how to look at the entire lifespan of their patients.”

Dr. Praszek tries to see every patient on the hospice unit each day she is on service. She also works closely with the interdisciplinary team at Hospice of East Texas. Routine care on the unit is provided by hospital staff, while the hospice team provides care management and oversight. Hospice care generally involves fewer intensive medical procedures and more intensive nursing care and comfort measures.

A Deeper Commitment

“My life today is the way it is because I really love my work,” says Dr. Praszek. She brings a lot of it home at night. In fact, Dr. Brown says he occasionally worries about the long hours she works. “But we try to make sure she gets the support she needs.”

“My door is always open,” adds Dr. Praszek. “I’m still learning from the nurses, and I’ve had housekeeping staff give me advice. When they find out my background [as a nurse’s aide], they always say, ‘Oh, that’s why we get along so well.’ ” TH

Larry Beresford wrote about hospitalists who work as administrators in the July issue.

When Karie Praszek, MD, a hospitalist at the University of Texas Health Center at Tyler (UTHCT) found out this past fall that she was being considered for the position of medical director of the hospital’s planned hospice inpatient unit, she went home after work and cried. These were tears of happiness because she was finally going to be able to combine her two loves as a physician: hospital medicine and hospice care. “It was like coming full circle,” she explains.

The seven-bed hospice unit at UTHCT opened in partnership with Hospice of East Texas in Tyler in November, following renovations to create more comfortable and spacious rooms. It is one of a growing number of collaborations between hospitals and community hospice programs to provide institutional beds for terminally ill, hospice-enrolled patients in need of short-term inpatient care for symptom management.

In many hospitals, hospitalists are well positioned to provide planning, leadership, hospice referrals, or medical management of hospice units in the hospital. But few of them will follow a path like Dr. Praszek’s to the medical leadership of the hospice unit.

The Needs of End-of-Life Patients

Dr. Praszek’s commitment to the needs of patients facing the end of their lives took her from Texas to Oklahoma to Oregon and back to Texas. She has been a practicing hospitalist at UTHCT since 2004, but medicine wasn’t her first career. In the 1980s, as a computer expert for the U.S. Postal Service, she helped to automate postal facilities. She was well paid, she says, but something was missing in her life.

Wanting to make a meaningful contribution, Dr. Praszek became a volunteer candy striper at a hospital in Dallas. She learned about hospice while assigned to the oncology floor.

“When I started doing hospice care, I fell in love with it, and used volunteer work to hone my skills,” she says. She quit her job and moved to Oklahoma to attend a seminary with a specialized curriculum in death, dying, and grief counseling, all the while volunteering with hospice patients.

“They even trained me to be a certified nurse’s aide,” she says. “I just wanted to do whatever they needed—to do what no one else wanted to do.”

As a volunteer nurse’s aide she cleaned bedpans, changed diapers, and gave bed baths to hospice patients. “I didn’t mind it because it meant I could have more time to talk with the patients,” explains Dr. Praszek.

A turning point came while she was on a hospice wing of a nursing home, working with a patient who had metastatic prostate cancer and was in excruciating pain. “You could hear this gentleman moaning when you entered the building,” she recalls.

The nurses on the unit turned to Dr. Praszek and asked her to call the patient’s physician for an order for more pain medications. “I said, ‘I’m just a volunteer,’ but they told me, ‘You’re our last hope,’ ” recounts Dr. Praszek. “So I called the doctor, and he said he wouldn’t order any more pain medications because he didn’t want the terminally ill patient to become an addict. Then he said, ‘I’m the doctor and you’re not,’ and hung up on me. I thought, well, you so-and-so. I’ll go to medical school instead of nursing school, which I had been considering, so that nobody can ever pull this kind of thing on me again.”

Dr. Praszek completed her pre-med courses, but put off applying because she was afraid that she was too old or not smart enough. Finally, with her husband’s encouragement, she applied to Oregon Health Sciences University and, on her 40th birthday in 1996, received notification of acceptance. Looking for students with significant life experience, the medical school offered Dr. Praszek a full scholarship. She graduated at the head of her class.

After completing her internal medicine residency, she couldn’t find a hospice-related position, but she had learned to appreciate the pace and complexity of hospital medicine. After doing locum tenens (temporary assignments), she landed in the hospitalist position at UTHCT. The 100-bed facility began as a tuberculosis hospital housed in a former U.S. Army base in 1949, and in 1977 it became part of the University of Texas health system.

Today Dr. Praszek heads a three-person hospital medicine department, with another physician and a physician’s assistant and the backup of 10 clinic physicians for after-hours coverage. Her job combines both clinical and administrative responsibilities, including risk assessments, protocol development, and the ethics committee. Roughly 10% of her time is devoted to patients on the hospice unit.

Providing Necessary Care

Hospice is an approach to the care of patients with life-limiting illnesses and their families, emphasizing the relief of pain and other symptoms, maximizing quality of life and support for the emotional and spiritual issues that come up at this time of life. Under the Medicare Hospice Benefit (introduced in 1983) Medicare-certified hospice programs are responsible for providing essentially all of the care needed to manage their enrolled patients, who have a life expectancy of six months or less. Medicare pays the hospice a daily packaged rate for its services—all-inclusive except for attending or consulting physicians, who are able to bill separately. Although the hospice benefit is primarily intended as a service in the patient’s home or other place of residence, such as a nursing home, often terminally ill patients require inpatient care for short periods to bring their medical symptoms under control.

To fill this need, hospice programs can open their own freestanding inpatient facilities, as Hospice of East Texas did with its 28-bed HomePlace, or else contract with a hospital for inpatient beds, as the hospice did with UTHCT. Those involved in planning the hospice unit at UTHCT emphasize that at the rate Medicare pays for inpatient hospice care ($562.69 per day, regionally adjusted), neither partner is likely to derive a profit from it. Instead the unit reflects a true commitment by both to meeting the needs of terminally ill patients in the hospital.

“This hospice unit was the right thing to do,” says UTHCT’s Chief Medical Officer Steven Brown, MD. “It’s an opportunity to educate our medical staff about end-of-life care, introduce the concept of hospice into the hospital, and improve utilization,” by changing the focus of treatment for those who choose the hospice approach.

The unit also provides an opportunity to concentrate palliative care training for nurses on the floor, which includes neuro-restorative and tuberculosis beds as well as non-dedicated hospice beds. Many patients are simultaneously referred to the unit and to Hospice of East Texas, while others may receive hospice care at home at the time of their placement on the unit.

Bring Inpatient Care Closer to Families

Marjorie Ream, CEO of Hospice of East Texas, explains that the origins of the hospice unit at UTHCT are in response to her agency’s family satisfaction surveys. Some families in the northeastern corner of the agency’s 13-county service area said they drove too far to visit loved ones at its HomePlace inpatient facility.

“We looked at our mission statement and started to explore how to make inpatient care available closer to the folks we serve,” says Ream. “I started a dialogue with Dr. Kirk Calhoun, the hospital’s president.”

Coincidentally, Dr. Calhoun had attended a hospital conference where he learned about a collaboration between a public charity hospital and a hospice in Atlanta that had received recognition from the American Hospital Association.

Their first meeting to discuss collaborating was in August 2005, and by November 15 the renovated unit was in operation, with two-room suites large enough to allow the patient’s family members to stay overnight on pullout sofas. Dr. Praszek’s name entered the dialogue after she gave a hospital lecture on end-of-life care and code status. “When we talked with her and she shared her career journey, we could see that she was a logical fit,” explains Ream. “And she really wanted to do this.

“My impression is that Dr. Praszek has a true ‘hospice heart.’ She really understands the interdisciplinary team. She’s an expert clinician, and she understands the differences in treating terminally ill patients. She has a real sense of the patient and family as people,” says Ream. “Nurses love her commitment and enthusiasm and are proud to be her colleagues.”

Dr. Praszek’s first concern is keeping people healthy. “To be a hospitalist on a hospice unit, you have to know how to change your focus from cure to caring,” she says. “It takes someone who is not afraid of confronting their patients’—or their own—mortality. When we first opened the unit, there was a sharp learning curve for physicians in the hospital. But it’s been a pretty smooth transition overall, except for one or two who still have a hard time recognizing when their patient is dying. Most physicians at this institution are learning how to look at the entire lifespan of their patients.”

Dr. Praszek tries to see every patient on the hospice unit each day she is on service. She also works closely with the interdisciplinary team at Hospice of East Texas. Routine care on the unit is provided by hospital staff, while the hospice team provides care management and oversight. Hospice care generally involves fewer intensive medical procedures and more intensive nursing care and comfort measures.

A Deeper Commitment

“My life today is the way it is because I really love my work,” says Dr. Praszek. She brings a lot of it home at night. In fact, Dr. Brown says he occasionally worries about the long hours she works. “But we try to make sure she gets the support she needs.”

“My door is always open,” adds Dr. Praszek. “I’m still learning from the nurses, and I’ve had housekeeping staff give me advice. When they find out my background [as a nurse’s aide], they always say, ‘Oh, that’s why we get along so well.’ ” TH

Larry Beresford wrote about hospitalists who work as administrators in the July issue.

Working hospitalists frequently find themselves leading quality initiatives, writing care protocols, sitting on a variety of committees, or engaged in other activities aimed at improving the hospital environment as a whole—not just the care of individual patients. Some even direct their hospital medicine group.

For many hospitalists, such activities may be auditions for progressively greater management responsibilities, eventually leading to physician executive positions, perhaps even leaving clinical practice behind. Experience as a hospitalist can be helpful when moving up the career ladder, say those who have followed this path, but advances also pose trade-offs in their working lives.

Hospital medicine can offer some of the best opportunities in all of healthcare for physicians to transition into administrative or executive positions, says SHM CEO Larry Wellikson, MD, FACP. “I believe that in 15 years or less, a quarter of hospital CEOs and half of hospital chief medical officers will have started their careers as hospitalists,” he predicts.

Such demand for hospitalists-turned-executives raises important implications for the field, and for SHM because many who make the transition will lack formal management training, says Dr. Wellikson.

“I keep hearing from 37-year-old hospitalists who are sitting at the table with healthcare management types,” he adds. “They feel they are at a distinct disadvantage because they never learned the essential management skills.”

SHM plans to explore collaborations with other healthcare organizations to develop a comprehensive management curriculum that could be completed by working hospitalists during one weekend a month over the course of several years. SHM already offers a four-day intensive Leadership Academy. (See “Society Pages,” p. 8.)

Defining Moments

Some of those who have made the transition say management is the last thing they expected to do when they entered medicine. One of these hospitalists is Russell L. Holman, MD, SHM president-elect and senior vice president and national medical director of Cogent Healthcare, Irvine, Calif.

“I believe my career has been marked by a series of defining moments, with one opportunity following another,” he says. “If you had asked me 15 years ago if I would be in this position, I’d have said, ‘Hell no!’ I had absolutely no interest in the business side of medicine and, frankly, I found it boring.”

Dr. Holman was initially drawn to internal medicine for the opportunity to establish long-term relationships with his patients, but then found that his residency training had really prepared him more for working in the hospital.

“I also found myself drawn to the challenge of the hospital environment and its very ill patients, with the opportunity to establish rapport and trust in a short period of time and achieve significant improvements in their care quickly,” he explains. He was also drawn to the environment. “I viewed the hospital as a complex setting to navigate, and I saw a lot of opportunities for improvement overall—which was also an opportunity for professional growth and accomplishment.”

During Dr. Holman’s year as chief resident, he realized that meetings with administrators and non-physician clinical personnel could be vehicles to accomplish larger goals. “I also began to experience the vicarious rewards that can be achieved from the accomplishments of others through the administrator’s role of making it easier for them to do their jobs,” he says.

Along the way, Dr. Holman’s mentors encouraged him to recognize an aptitude for management and seek additional opportunities to practice it. On his own, he recognized his need for professional development opportunities to acquire management skills. He took weekend seminars and attended conferences to help him learn how to run effective team meetings, communicate with colleagues, and approach financial reports. Combined interests in teaching and management led Dr. Holman to the chair of the SHM Leadership Development Task Force. He became course director for its Leadership Academy, first offered in 2005.

The Ideal Hospitalist Program

Stacy Goldsholl, MD, president of the Hospital Medicine Division of TeamHealth, Knoxville, Tenn., was a working hospitalist for 11 years before making the move.

“Along the way, I started to develop a real sense of what my own ideal hospital medicine program would look like, not just in terms of clinical excellence, but also physician professional satisfaction,” she says. Dr. Goldsholl worked in several hospitalist groups in different parts of the country, running one group and later setting up an 11-member hospitalist practice from scratch in Pennsylvania, with a 50% time commitment for administrative work.

“How did I prepare for that role? A lot of it is seat-of-your-pants, although a mentor had pointed me toward a physician management training course,” she said. Last year Dr. Goldsholl joined TeamHealth and became 100% administrative. “It’s a double-edged sword, giving up the clinical piece. Part of the success of any physician executive is having a passion for patient care. Clinical work is something I definitely miss. But the higher goal is to impact larger health systems.”

Dr. Goldsholl’s current job includes standardizing TeamHealth’s hospitalist practices nationwide, providing leadership for regional directors, and reporting on quality indicators. “But the biggest piece of my current job is business development—going out to meet with clients,” she explains. Those clients include hospital executives and potential acquisition partners.

“Is this a path for other hospitalists?” asks Dr. Goldsholl. “Absolutely. Not necessarily my exact role, but jobs like vice president of medical affairs for a hospital, patient safety officer, CEO, or medical director of a medical company. Those positions will be filled by hospitalists. Physicians who choose to be hospitalists already see themselves as change agents, so many will gravitate toward a leadership role. Young hospitalists with that same passion, once they come to understand the health care system, it ignites their passion to make things better on a larger scale.”

Hospitalist David Bowman, MD, has been executive director of the Tucson, Ariz., Region of IPC—the Hospitalist Company since 2000, after playing major roles in establishing medical practices and a physician’s organization. Today he is the only physician among the company’s executive directors. “Those guys are smart,” he says. “They look at medicine from a higher level.”

Dr. Bowman, like Drs. Holman and Goldsholl, sometimes thinks about pursuing a master’s degree. But he is reluctant to take the time away from what he is now doing.

“I don’t think I could go further than I have without the letters MBA after my name,” he speculates. “But I’m happy enough where I am and, if need be, I could still go back to hospitalist work.”

Dr. Bowman found his initial foray into administration as head of a five-member group practice. “At 7:30 at night I’d be signing checks,” he recalls. “If there was any money left over, the last check would be my own salary.”

Today his position is 75% administrative and 25% clinical. He has been able to get his fill of clinical work by taking hospitalist shifts evenings and weekends. “I don’t want to lose my medical skills, but I like administration much more than I thought I would,” he says. “What I have learned is just how much it takes to support the physician who walks up to the patient’s chart, opens it, writes an order for an MRI of the brain, and then closes the chart again. It’s mind-boggling how complex the system is in supporting that 30-second action—how many other people are involved in making it happen, all of the areas for potential error. That’s why we work so hard on patient safety—which has to start at the top and flow from there.”

Career Crossroads

Finding a significant administrative role is not an all-or-nothing proposition for working hospitalists, although directors of group practices sometimes struggle for their colleagues’ recognition of their need for dedicated administrative time.

Doctors face two significant crossroads as they gain progressive administrative responsibilities. For those with demanding executive positions, it may become necessary to give up clinical practice—a painful choice for doctors who have devoted years to mastering medical care. Physician executives eventually may also face the need to obtain a management degree such as an MBA or a master’s of health administration—or else find other, less time-consuming ways to learn essential management skills.

Patrick Cawley, MD, is a hospitalist who has not given up clinical work, even while his administrative responsibilities have grown. In his current position as executive medical director of Medical University of South Carolina (MUSC) Medical Center, Charleston, clinical duties take up about 30% of the job. He is just a couple of courses short of completing an MBA from the University of Massachusetts.

“Basically, I’m the hospital’s chief medical officer,” says Dr. Cawley. “A chief medical officer attends a lot of meetings. Most of my day is spent interacting with different people in the hospital—other administrators or one-on-one with physicians. My purview is quality, patient safety, and clinical effectiveness—providing the strategic vision for those activities and some level of detail in working projects through the system.” The role is part cheerleader and part task-master, he says, requiring skills in communications, negotiations and conflict management.

“There’s no doubt that I’m having trouble carving out 30% of my time for clinical work,” admits Dr. Cawley. “You end up missing a meeting here and there, and that’s not good. I know I’ll have to decrease my clinical time eventually.”

For now, however, Dr. Cawley is able to find clinical time in two- to three-hour increments, primarily for teaching and rounding with residents.

“Chief medical officers argue about this all the time: Should you be practicing medicine or not?” he says. “My personal take is that I prefer to do some clinical work. It keeps me involved in the day-to-day problems of physicians and the operations of the hospital. I don’t think I’ll ever give it up completely. For physician leaders, it’s important to be respected clinically, and it gives you a step up in professional relations.”

Dilemmas and Downsides

Research by Timothy Hoff of the University at Albany, N.Y., and others suggests that physician executives who continue to see patients part-time are happier in their jobs, says Winthrop Whitcomb, MD, a hospitalist at Mercy Medical Center in Springfield, Mass. Dr. Whitcomb is a member of SHM’s Career Satisfaction Task Force, which is also studying the issue. Also, when clinical commitments shrink, it can be a challenge to remain current with clinical skills, medical literature, and advances in healthcare technology and computerization.

“There is a danger in dropping out of medicine and pigeonholing yourself too early in your career—especially if you are taking an administrative job for the wrong reasons, such as temporary job frustrations,” warns Dr. Whitcomb. “It’s very hard to come back to clinical practice after giving it up.”

SHM’s Career Satisfaction Task Force is developing a career satisfaction self-assessment tool that would help working hospitalists make clearer assessments of the dilemmas of considering a career change.

Physician executives need to be clear on their loyalties as well as their stakeholders, adds Dr. Wellikson, who gave up his clinical practice in 2000. “At the end of the day, my value to my company was not in taking care of patients,” he says. “Yes, you need to keep yourself real in your relations with other doctors—but seeing patients is not the only way to do that. We don’t need Lee Iacocca building the cars he sells, even though he started as an automobile engineer.”

Dr. Wellikson reminds hospitalists that management “isn’t all fun and games. Your group expects you to fight for them. Not everybody sees you in the best light. Sometimes leadership can be lonely, and there’s no road map. You can’t always say ‘yes.’ Sometimes you need to fire colleagues.”

How to Get Started

When working hospitalists get exposed to administrative or quality improvement projects and opportunities, some of those projects will be successful and satisfying, while others will not. But even if their goal isn’t to become the CEO of a national organization, they can gain a sense of their interests and aptitudes. Other part-time administrative roles include associate medical director of a group practice, quality officer for the hospital, or medical director of informatics.

Just look around the hospital and see what’s broken, suggests Dr. Cawley. “Or else go down to the quality department and volunteer your services,” he advises. “There are innumerable tasks that need to be done. I would recommend starting small. Do projects that involve small groups working together. As the projects get bigger, they will involve more people, more resources, more measurement tools. This will then give you a sense of whether you want to continue in management.”

When a hospitalist gets appointed to a quality committee, it is important to be an active contributor. “Take a forward stance. Prepare for the meetings,” adds Dr. Holman. Go back to your constituency and have an active discussion about the project. By that very experience you will be viewed as a leader—and recognized leaders are the people who are given larger-scale opportunities.”

Dr. Goldsholl insists, “The way to be successful as a leader is to continue to be passionate about patient care. At the same time, continue to develop yourself with the tools and skills needed to make the case for hospital medicine. If you can do both, your chances of success are higher.”

It is also important to develop people skills—some of which can be learned. “Did I have all of those skills in the beginning?” asks Dr. Goldsholl. “Absolutely not. A certain maturity and ability to be flexible were acquired over time. At first I did not know how important it was in the first five minutes of a business conversation to ask the person I’m talking to about their children. That’s something else I didn’t learn in medical school.” TH

Larry Beresford is based in Oakland, Calif.

Working hospitalists frequently find themselves leading quality initiatives, writing care protocols, sitting on a variety of committees, or engaged in other activities aimed at improving the hospital environment as a whole—not just the care of individual patients. Some even direct their hospital medicine group.

For many hospitalists, such activities may be auditions for progressively greater management responsibilities, eventually leading to physician executive positions, perhaps even leaving clinical practice behind. Experience as a hospitalist can be helpful when moving up the career ladder, say those who have followed this path, but advances also pose trade-offs in their working lives.

Hospital medicine can offer some of the best opportunities in all of healthcare for physicians to transition into administrative or executive positions, says SHM CEO Larry Wellikson, MD, FACP. “I believe that in 15 years or less, a quarter of hospital CEOs and half of hospital chief medical officers will have started their careers as hospitalists,” he predicts.

Such demand for hospitalists-turned-executives raises important implications for the field, and for SHM because many who make the transition will lack formal management training, says Dr. Wellikson.

“I keep hearing from 37-year-old hospitalists who are sitting at the table with healthcare management types,” he adds. “They feel they are at a distinct disadvantage because they never learned the essential management skills.”

SHM plans to explore collaborations with other healthcare organizations to develop a comprehensive management curriculum that could be completed by working hospitalists during one weekend a month over the course of several years. SHM already offers a four-day intensive Leadership Academy. (See “Society Pages,” p. 8.)

Defining Moments

Some of those who have made the transition say management is the last thing they expected to do when they entered medicine. One of these hospitalists is Russell L. Holman, MD, SHM president-elect and senior vice president and national medical director of Cogent Healthcare, Irvine, Calif.

“I believe my career has been marked by a series of defining moments, with one opportunity following another,” he says. “If you had asked me 15 years ago if I would be in this position, I’d have said, ‘Hell no!’ I had absolutely no interest in the business side of medicine and, frankly, I found it boring.”

Dr. Holman was initially drawn to internal medicine for the opportunity to establish long-term relationships with his patients, but then found that his residency training had really prepared him more for working in the hospital.

“I also found myself drawn to the challenge of the hospital environment and its very ill patients, with the opportunity to establish rapport and trust in a short period of time and achieve significant improvements in their care quickly,” he explains. He was also drawn to the environment. “I viewed the hospital as a complex setting to navigate, and I saw a lot of opportunities for improvement overall—which was also an opportunity for professional growth and accomplishment.”

During Dr. Holman’s year as chief resident, he realized that meetings with administrators and non-physician clinical personnel could be vehicles to accomplish larger goals. “I also began to experience the vicarious rewards that can be achieved from the accomplishments of others through the administrator’s role of making it easier for them to do their jobs,” he says.

Along the way, Dr. Holman’s mentors encouraged him to recognize an aptitude for management and seek additional opportunities to practice it. On his own, he recognized his need for professional development opportunities to acquire management skills. He took weekend seminars and attended conferences to help him learn how to run effective team meetings, communicate with colleagues, and approach financial reports. Combined interests in teaching and management led Dr. Holman to the chair of the SHM Leadership Development Task Force. He became course director for its Leadership Academy, first offered in 2005.

The Ideal Hospitalist Program

Stacy Goldsholl, MD, president of the Hospital Medicine Division of TeamHealth, Knoxville, Tenn., was a working hospitalist for 11 years before making the move.

“Along the way, I started to develop a real sense of what my own ideal hospital medicine program would look like, not just in terms of clinical excellence, but also physician professional satisfaction,” she says. Dr. Goldsholl worked in several hospitalist groups in different parts of the country, running one group and later setting up an 11-member hospitalist practice from scratch in Pennsylvania, with a 50% time commitment for administrative work.

“How did I prepare for that role? A lot of it is seat-of-your-pants, although a mentor had pointed me toward a physician management training course,” she said. Last year Dr. Goldsholl joined TeamHealth and became 100% administrative. “It’s a double-edged sword, giving up the clinical piece. Part of the success of any physician executive is having a passion for patient care. Clinical work is something I definitely miss. But the higher goal is to impact larger health systems.”

Dr. Goldsholl’s current job includes standardizing TeamHealth’s hospitalist practices nationwide, providing leadership for regional directors, and reporting on quality indicators. “But the biggest piece of my current job is business development—going out to meet with clients,” she explains. Those clients include hospital executives and potential acquisition partners.

“Is this a path for other hospitalists?” asks Dr. Goldsholl. “Absolutely. Not necessarily my exact role, but jobs like vice president of medical affairs for a hospital, patient safety officer, CEO, or medical director of a medical company. Those positions will be filled by hospitalists. Physicians who choose to be hospitalists already see themselves as change agents, so many will gravitate toward a leadership role. Young hospitalists with that same passion, once they come to understand the health care system, it ignites their passion to make things better on a larger scale.”

Hospitalist David Bowman, MD, has been executive director of the Tucson, Ariz., Region of IPC—the Hospitalist Company since 2000, after playing major roles in establishing medical practices and a physician’s organization. Today he is the only physician among the company’s executive directors. “Those guys are smart,” he says. “They look at medicine from a higher level.”

Dr. Bowman, like Drs. Holman and Goldsholl, sometimes thinks about pursuing a master’s degree. But he is reluctant to take the time away from what he is now doing.

“I don’t think I could go further than I have without the letters MBA after my name,” he speculates. “But I’m happy enough where I am and, if need be, I could still go back to hospitalist work.”

Dr. Bowman found his initial foray into administration as head of a five-member group practice. “At 7:30 at night I’d be signing checks,” he recalls. “If there was any money left over, the last check would be my own salary.”

Today his position is 75% administrative and 25% clinical. He has been able to get his fill of clinical work by taking hospitalist shifts evenings and weekends. “I don’t want to lose my medical skills, but I like administration much more than I thought I would,” he says. “What I have learned is just how much it takes to support the physician who walks up to the patient’s chart, opens it, writes an order for an MRI of the brain, and then closes the chart again. It’s mind-boggling how complex the system is in supporting that 30-second action—how many other people are involved in making it happen, all of the areas for potential error. That’s why we work so hard on patient safety—which has to start at the top and flow from there.”

Career Crossroads

Finding a significant administrative role is not an all-or-nothing proposition for working hospitalists, although directors of group practices sometimes struggle for their colleagues’ recognition of their need for dedicated administrative time.

Doctors face two significant crossroads as they gain progressive administrative responsibilities. For those with demanding executive positions, it may become necessary to give up clinical practice—a painful choice for doctors who have devoted years to mastering medical care. Physician executives eventually may also face the need to obtain a management degree such as an MBA or a master’s of health administration—or else find other, less time-consuming ways to learn essential management skills.

Patrick Cawley, MD, is a hospitalist who has not given up clinical work, even while his administrative responsibilities have grown. In his current position as executive medical director of Medical University of South Carolina (MUSC) Medical Center, Charleston, clinical duties take up about 30% of the job. He is just a couple of courses short of completing an MBA from the University of Massachusetts.

“Basically, I’m the hospital’s chief medical officer,” says Dr. Cawley. “A chief medical officer attends a lot of meetings. Most of my day is spent interacting with different people in the hospital—other administrators or one-on-one with physicians. My purview is quality, patient safety, and clinical effectiveness—providing the strategic vision for those activities and some level of detail in working projects through the system.” The role is part cheerleader and part task-master, he says, requiring skills in communications, negotiations and conflict management.

“There’s no doubt that I’m having trouble carving out 30% of my time for clinical work,” admits Dr. Cawley. “You end up missing a meeting here and there, and that’s not good. I know I’ll have to decrease my clinical time eventually.”

For now, however, Dr. Cawley is able to find clinical time in two- to three-hour increments, primarily for teaching and rounding with residents.

“Chief medical officers argue about this all the time: Should you be practicing medicine or not?” he says. “My personal take is that I prefer to do some clinical work. It keeps me involved in the day-to-day problems of physicians and the operations of the hospital. I don’t think I’ll ever give it up completely. For physician leaders, it’s important to be respected clinically, and it gives you a step up in professional relations.”

Dilemmas and Downsides

Research by Timothy Hoff of the University at Albany, N.Y., and others suggests that physician executives who continue to see patients part-time are happier in their jobs, says Winthrop Whitcomb, MD, a hospitalist at Mercy Medical Center in Springfield, Mass. Dr. Whitcomb is a member of SHM’s Career Satisfaction Task Force, which is also studying the issue. Also, when clinical commitments shrink, it can be a challenge to remain current with clinical skills, medical literature, and advances in healthcare technology and computerization.

“There is a danger in dropping out of medicine and pigeonholing yourself too early in your career—especially if you are taking an administrative job for the wrong reasons, such as temporary job frustrations,” warns Dr. Whitcomb. “It’s very hard to come back to clinical practice after giving it up.”

SHM’s Career Satisfaction Task Force is developing a career satisfaction self-assessment tool that would help working hospitalists make clearer assessments of the dilemmas of considering a career change.

Physician executives need to be clear on their loyalties as well as their stakeholders, adds Dr. Wellikson, who gave up his clinical practice in 2000. “At the end of the day, my value to my company was not in taking care of patients,” he says. “Yes, you need to keep yourself real in your relations with other doctors—but seeing patients is not the only way to do that. We don’t need Lee Iacocca building the cars he sells, even though he started as an automobile engineer.”

Dr. Wellikson reminds hospitalists that management “isn’t all fun and games. Your group expects you to fight for them. Not everybody sees you in the best light. Sometimes leadership can be lonely, and there’s no road map. You can’t always say ‘yes.’ Sometimes you need to fire colleagues.”

How to Get Started

When working hospitalists get exposed to administrative or quality improvement projects and opportunities, some of those projects will be successful and satisfying, while others will not. But even if their goal isn’t to become the CEO of a national organization, they can gain a sense of their interests and aptitudes. Other part-time administrative roles include associate medical director of a group practice, quality officer for the hospital, or medical director of informatics.

Just look around the hospital and see what’s broken, suggests Dr. Cawley. “Or else go down to the quality department and volunteer your services,” he advises. “There are innumerable tasks that need to be done. I would recommend starting small. Do projects that involve small groups working together. As the projects get bigger, they will involve more people, more resources, more measurement tools. This will then give you a sense of whether you want to continue in management.”

When a hospitalist gets appointed to a quality committee, it is important to be an active contributor. “Take a forward stance. Prepare for the meetings,” adds Dr. Holman. Go back to your constituency and have an active discussion about the project. By that very experience you will be viewed as a leader—and recognized leaders are the people who are given larger-scale opportunities.”

Dr. Goldsholl insists, “The way to be successful as a leader is to continue to be passionate about patient care. At the same time, continue to develop yourself with the tools and skills needed to make the case for hospital medicine. If you can do both, your chances of success are higher.”

It is also important to develop people skills—some of which can be learned. “Did I have all of those skills in the beginning?” asks Dr. Goldsholl. “Absolutely not. A certain maturity and ability to be flexible were acquired over time. At first I did not know how important it was in the first five minutes of a business conversation to ask the person I’m talking to about their children. That’s something else I didn’t learn in medical school.” TH

Larry Beresford is based in Oakland, Calif.

Working hospitalists frequently find themselves leading quality initiatives, writing care protocols, sitting on a variety of committees, or engaged in other activities aimed at improving the hospital environment as a whole—not just the care of individual patients. Some even direct their hospital medicine group.

For many hospitalists, such activities may be auditions for progressively greater management responsibilities, eventually leading to physician executive positions, perhaps even leaving clinical practice behind. Experience as a hospitalist can be helpful when moving up the career ladder, say those who have followed this path, but advances also pose trade-offs in their working lives.

Hospital medicine can offer some of the best opportunities in all of healthcare for physicians to transition into administrative or executive positions, says SHM CEO Larry Wellikson, MD, FACP. “I believe that in 15 years or less, a quarter of hospital CEOs and half of hospital chief medical officers will have started their careers as hospitalists,” he predicts.

Such demand for hospitalists-turned-executives raises important implications for the field, and for SHM because many who make the transition will lack formal management training, says Dr. Wellikson.

“I keep hearing from 37-year-old hospitalists who are sitting at the table with healthcare management types,” he adds. “They feel they are at a distinct disadvantage because they never learned the essential management skills.”

SHM plans to explore collaborations with other healthcare organizations to develop a comprehensive management curriculum that could be completed by working hospitalists during one weekend a month over the course of several years. SHM already offers a four-day intensive Leadership Academy. (See “Society Pages,” p. 8.)

Defining Moments

Some of those who have made the transition say management is the last thing they expected to do when they entered medicine. One of these hospitalists is Russell L. Holman, MD, SHM president-elect and senior vice president and national medical director of Cogent Healthcare, Irvine, Calif.

“I believe my career has been marked by a series of defining moments, with one opportunity following another,” he says. “If you had asked me 15 years ago if I would be in this position, I’d have said, ‘Hell no!’ I had absolutely no interest in the business side of medicine and, frankly, I found it boring.”

Dr. Holman was initially drawn to internal medicine for the opportunity to establish long-term relationships with his patients, but then found that his residency training had really prepared him more for working in the hospital.

“I also found myself drawn to the challenge of the hospital environment and its very ill patients, with the opportunity to establish rapport and trust in a short period of time and achieve significant improvements in their care quickly,” he explains. He was also drawn to the environment. “I viewed the hospital as a complex setting to navigate, and I saw a lot of opportunities for improvement overall—which was also an opportunity for professional growth and accomplishment.”

During Dr. Holman’s year as chief resident, he realized that meetings with administrators and non-physician clinical personnel could be vehicles to accomplish larger goals. “I also began to experience the vicarious rewards that can be achieved from the accomplishments of others through the administrator’s role of making it easier for them to do their jobs,” he says.

Along the way, Dr. Holman’s mentors encouraged him to recognize an aptitude for management and seek additional opportunities to practice it. On his own, he recognized his need for professional development opportunities to acquire management skills. He took weekend seminars and attended conferences to help him learn how to run effective team meetings, communicate with colleagues, and approach financial reports. Combined interests in teaching and management led Dr. Holman to the chair of the SHM Leadership Development Task Force. He became course director for its Leadership Academy, first offered in 2005.

The Ideal Hospitalist Program

Stacy Goldsholl, MD, president of the Hospital Medicine Division of TeamHealth, Knoxville, Tenn., was a working hospitalist for 11 years before making the move.

“Along the way, I started to develop a real sense of what my own ideal hospital medicine program would look like, not just in terms of clinical excellence, but also physician professional satisfaction,” she says. Dr. Goldsholl worked in several hospitalist groups in different parts of the country, running one group and later setting up an 11-member hospitalist practice from scratch in Pennsylvania, with a 50% time commitment for administrative work.

“How did I prepare for that role? A lot of it is seat-of-your-pants, although a mentor had pointed me toward a physician management training course,” she said. Last year Dr. Goldsholl joined TeamHealth and became 100% administrative. “It’s a double-edged sword, giving up the clinical piece. Part of the success of any physician executive is having a passion for patient care. Clinical work is something I definitely miss. But the higher goal is to impact larger health systems.”

Dr. Goldsholl’s current job includes standardizing TeamHealth’s hospitalist practices nationwide, providing leadership for regional directors, and reporting on quality indicators. “But the biggest piece of my current job is business development—going out to meet with clients,” she explains. Those clients include hospital executives and potential acquisition partners.

“Is this a path for other hospitalists?” asks Dr. Goldsholl. “Absolutely. Not necessarily my exact role, but jobs like vice president of medical affairs for a hospital, patient safety officer, CEO, or medical director of a medical company. Those positions will be filled by hospitalists. Physicians who choose to be hospitalists already see themselves as change agents, so many will gravitate toward a leadership role. Young hospitalists with that same passion, once they come to understand the health care system, it ignites their passion to make things better on a larger scale.”

Hospitalist David Bowman, MD, has been executive director of the Tucson, Ariz., Region of IPC—the Hospitalist Company since 2000, after playing major roles in establishing medical practices and a physician’s organization. Today he is the only physician among the company’s executive directors. “Those guys are smart,” he says. “They look at medicine from a higher level.”

Dr. Bowman, like Drs. Holman and Goldsholl, sometimes thinks about pursuing a master’s degree. But he is reluctant to take the time away from what he is now doing.

“I don’t think I could go further than I have without the letters MBA after my name,” he speculates. “But I’m happy enough where I am and, if need be, I could still go back to hospitalist work.”

Dr. Bowman found his initial foray into administration as head of a five-member group practice. “At 7:30 at night I’d be signing checks,” he recalls. “If there was any money left over, the last check would be my own salary.”

Today his position is 75% administrative and 25% clinical. He has been able to get his fill of clinical work by taking hospitalist shifts evenings and weekends. “I don’t want to lose my medical skills, but I like administration much more than I thought I would,” he says. “What I have learned is just how much it takes to support the physician who walks up to the patient’s chart, opens it, writes an order for an MRI of the brain, and then closes the chart again. It’s mind-boggling how complex the system is in supporting that 30-second action—how many other people are involved in making it happen, all of the areas for potential error. That’s why we work so hard on patient safety—which has to start at the top and flow from there.”

Career Crossroads

Finding a significant administrative role is not an all-or-nothing proposition for working hospitalists, although directors of group practices sometimes struggle for their colleagues’ recognition of their need for dedicated administrative time.

Doctors face two significant crossroads as they gain progressive administrative responsibilities. For those with demanding executive positions, it may become necessary to give up clinical practice—a painful choice for doctors who have devoted years to mastering medical care. Physician executives eventually may also face the need to obtain a management degree such as an MBA or a master’s of health administration—or else find other, less time-consuming ways to learn essential management skills.

Patrick Cawley, MD, is a hospitalist who has not given up clinical work, even while his administrative responsibilities have grown. In his current position as executive medical director of Medical University of South Carolina (MUSC) Medical Center, Charleston, clinical duties take up about 30% of the job. He is just a couple of courses short of completing an MBA from the University of Massachusetts.

“Basically, I’m the hospital’s chief medical officer,” says Dr. Cawley. “A chief medical officer attends a lot of meetings. Most of my day is spent interacting with different people in the hospital—other administrators or one-on-one with physicians. My purview is quality, patient safety, and clinical effectiveness—providing the strategic vision for those activities and some level of detail in working projects through the system.” The role is part cheerleader and part task-master, he says, requiring skills in communications, negotiations and conflict management.

“There’s no doubt that I’m having trouble carving out 30% of my time for clinical work,” admits Dr. Cawley. “You end up missing a meeting here and there, and that’s not good. I know I’ll have to decrease my clinical time eventually.”

For now, however, Dr. Cawley is able to find clinical time in two- to three-hour increments, primarily for teaching and rounding with residents.

“Chief medical officers argue about this all the time: Should you be practicing medicine or not?” he says. “My personal take is that I prefer to do some clinical work. It keeps me involved in the day-to-day problems of physicians and the operations of the hospital. I don’t think I’ll ever give it up completely. For physician leaders, it’s important to be respected clinically, and it gives you a step up in professional relations.”

Dilemmas and Downsides

Research by Timothy Hoff of the University at Albany, N.Y., and others suggests that physician executives who continue to see patients part-time are happier in their jobs, says Winthrop Whitcomb, MD, a hospitalist at Mercy Medical Center in Springfield, Mass. Dr. Whitcomb is a member of SHM’s Career Satisfaction Task Force, which is also studying the issue. Also, when clinical commitments shrink, it can be a challenge to remain current with clinical skills, medical literature, and advances in healthcare technology and computerization.

“There is a danger in dropping out of medicine and pigeonholing yourself too early in your career—especially if you are taking an administrative job for the wrong reasons, such as temporary job frustrations,” warns Dr. Whitcomb. “It’s very hard to come back to clinical practice after giving it up.”

SHM’s Career Satisfaction Task Force is developing a career satisfaction self-assessment tool that would help working hospitalists make clearer assessments of the dilemmas of considering a career change.

Physician executives need to be clear on their loyalties as well as their stakeholders, adds Dr. Wellikson, who gave up his clinical practice in 2000. “At the end of the day, my value to my company was not in taking care of patients,” he says. “Yes, you need to keep yourself real in your relations with other doctors—but seeing patients is not the only way to do that. We don’t need Lee Iacocca building the cars he sells, even though he started as an automobile engineer.”

Dr. Wellikson reminds hospitalists that management “isn’t all fun and games. Your group expects you to fight for them. Not everybody sees you in the best light. Sometimes leadership can be lonely, and there’s no road map. You can’t always say ‘yes.’ Sometimes you need to fire colleagues.”

How to Get Started

When working hospitalists get exposed to administrative or quality improvement projects and opportunities, some of those projects will be successful and satisfying, while others will not. But even if their goal isn’t to become the CEO of a national organization, they can gain a sense of their interests and aptitudes. Other part-time administrative roles include associate medical director of a group practice, quality officer for the hospital, or medical director of informatics.

Just look around the hospital and see what’s broken, suggests Dr. Cawley. “Or else go down to the quality department and volunteer your services,” he advises. “There are innumerable tasks that need to be done. I would recommend starting small. Do projects that involve small groups working together. As the projects get bigger, they will involve more people, more resources, more measurement tools. This will then give you a sense of whether you want to continue in management.”

When a hospitalist gets appointed to a quality committee, it is important to be an active contributor. “Take a forward stance. Prepare for the meetings,” adds Dr. Holman. Go back to your constituency and have an active discussion about the project. By that very experience you will be viewed as a leader—and recognized leaders are the people who are given larger-scale opportunities.”

Dr. Goldsholl insists, “The way to be successful as a leader is to continue to be passionate about patient care. At the same time, continue to develop yourself with the tools and skills needed to make the case for hospital medicine. If you can do both, your chances of success are higher.”

It is also important to develop people skills—some of which can be learned. “Did I have all of those skills in the beginning?” asks Dr. Goldsholl. “Absolutely not. A certain maturity and ability to be flexible were acquired over time. At first I did not know how important it was in the first five minutes of a business conversation to ask the person I’m talking to about their children. That’s something else I didn’t learn in medical school.” TH

Larry Beresford is based in Oakland, Calif.

Howard Epstein, a hospitalist at Regions Hospital in St. Paul, MN, spent nearly 2 years planning an inpatient palliative care consultation service for Regions before its launch in January of this year. A multidisciplinary advisory committee met monthly to help with the planning, and Dr. Epstein, the embryonic program’s medical director, went before the hospital’s administration to make the clinical and financial case for supporting it.

“What we’re trying to do is to take the basic interdisciplinary approach pioneered in hospice and move it upstream,” to help relieve suffering in seriously ill patients before they need or qualify for hospice care, he explains. “I just knew I wanted to incorporate it into a hospitalist model,” and into the Hospitalist Services Division’s weekly block schedule.

After the service was launched, it became clear that the schedule did not allow for the significant time commitment required to do palliative care, so a new approach is planned for July. Dr. Epstein and 6 other hospitalists participating in the palliative care service will divide up weekly blocks of time. Half of their duties while on service will be devoted to palliative care and the other half to covering 1 hospital unit as a hospitalist, rather than the usual 2 units for hospitalists at Regions.

The palliative care service at Regions, which includes a half-time chaplain and social worker and a full-time nurse practitioner, responds to consultation requests by doctors and nurses from all of the hospital’s adult services. The service also admits patients from HealthPartners’ affiliated hospice program when they are hospitalized at Regions for short-term symptom management or respite care.

Key to long-term success lies in documenting improved clinical outcomes, patient, family, and provider satisfaction, financial savings, and enhanced patient throughput. “I’m optimistic we’ll be able to demonstrate significant value, but if we can’t, we’ll be hard-pressed to get continued support,” he says. This challenge, he adds, is similar to what the hospitalist service at Regions faced when it was launched in 1998.

Palliative care is not a new concept in medicine, but it has enjoyed dramatic growth in recent years. The American Hospital Association estimates that 17% of community hospitals and 26% of academic teaching hospitals in the United States now have either a palliative care consultation service or a dedicated unit, although the former is more common because it can be established with a smaller fiscal outlay.

Palliative care aims to relieve suffering, broadly defined, for patients living with chronic, advanced illnesses. State-of-the-art pain management is a major emphasis for the interdisciplinary palliative care team, but so are addressing the patient and family’s emotional, psychological and spiritual concerns related to the illness and offering guidance for making informed treatment decisions that reflect their values and goals for care. Palliative care services generally target all patients with advanced illness from the point of diagnosis, simultaneous with any other medical treatment regimens.

Two Medical Fields Growing Together

“I believe hospitalist practices and palliative care services are of necessity growing closer together,” says Susan Block, codirector of the Harvard Medical School Center for Palliative Care in Boston, MA. The Harvard Center provides intensive palliative care training for clinicians who also have an interest in teaching.

“If you run a palliative care consult service or a palliative care unit, you are operating much like a hospitalist, with a focus on hospital systems and workload issues, communication, and getting people out of the hospital,” Dr. Block says. At the same time, most hospitalists deal with end-of-life issues and the challenges of relieving symptoms such as pain, delirium, or anxiety every day, whether they view their role in those terms or not.

Stephanie Grossman, a hospitalist at Emory Healthcare in Atlanta, GA, says she discovered personal satisfaction as a young physician in having meaningful conversations about care goals with seriously ill patients and leading family conferences, despite the time pressures of the job. The head of the hospital medicine service at Emory, Mark Williams, MD, told Dr. Grossman there was a name for what she enjoyed doing: palliative care. He encouraged her, along with colleague Melissa Mahoney, to obtain additional training in developing such a program, starting with a 2003 conference in San Diego sponsored by the Center to Advance Palliative Care.

“I came back from San Diego feeling swept away by how it really was possible to develop a financially feasible program,” says Dr. Grossman. Back at Emory, she and Dr. Mahoney joined a palliative care task force formed by Dr. Williams, with representatives from geriatrics, nursing, social work, chaplaincy, finance, and administration. This group provided input for a business plan for the palliative care service that will start in September at Emory Crawford Long and Emory University hospitals.

The 2 hospitalists, who have become certified in palliative medicine, will divide a full-time position as codirectors of the inpatient palliative care service in alternating monthly blocks, along with additional teaching responsibilities. Their 4-year plan is to add additional staffing as the program grows and to work with a geriatrician to develop a palliative care fellowship program. The palliative care team, including a nurse, social worker, and chaplain, will conduct daily palliative care rounds and biweekly interdisciplinary case conferences at the 2 hospitals.

“We have a nurse practitioner involved to help us coordinate between the 2 sites. We’ll go to various departments and do some grand rounds to introduce and market the program,” Dr. Grossman notes. In addition to practicing a style of medicine that offers deeper personal interactions with patients, she is excited to be part of creating a new program. However, she emphasizes the importance of having an executive champion within the hospital who understands financing, institutional politics, and how to recruit other champions. “We’ve been lucky to enjoy the support of Dr. Williams and [Emory Chief Operating Officer] Pete Basler. Dr. Mahoney and I have been working with hospitalists for several years, but our work has all been clinical,” she says.

Another challenge for hospitalists interested in pursuing palliative care include the need to make sure their new responsibilities are not just an add-on to a full-time job. The hospital needs to commit resources for planning and implementing a palliative care program, including a percentage of the hospitalist’s time, Dr. Block says. “Zero FTEs is not viable in the long run,” she adds.

Physician billing for palliative care consults can help offset the costs of running a service, but it is unlikely to break even on billing alone, says Eva Chittenden, a hospitalist and palliative care physician at the University of California-San Francisco, which has operated a palliative care service since 1999. Dr. Chittenden is also part of the Palliative Care Leadership Center at UCSF, which offers 2-day intensive training programs 4 times a year for hospital teams that want to start or strengthen inpatient palliative care services.

In most cases, palliative care requires financial support from the hospital, although it’s not difficult to justify that support by showing cost avoidance, reduced lengths of stay, and improved clinical outcomes, with the help of tools developed by the Center to Advance Palliative Care, Dr. Chittenden says. Program development also challenges the hospitalist’s leadership and marketing skills.

A Process of Growing Involvement

“What often happens with hospitalists is that they start out exploring palliative care, and it becomes very compelling,” Dr. Block adds. “The more competent you get at it, the more compelling it becomes. They find deeper meaning in their work. And then they’re hooked.”

A hospitalist can seek additional training and then incorporate palliative care tools, concepts, and perspectives into his or her daily work. An interest in palliative care may lead to involvement with the hospital ethics committee, a seat on a palliative care advisory committee, or a role in standards or protocol development, as well as pursuit of specialty certification in hospice and palliative medicine.

Although hospitalists may be obvious candidates to participate in more formal palliative care program development, “incorporating palliative care into a routine hospitalist practice is not a trivial thing,” Dr. Block adds. For starters, it requires additional training. “Most hospitalists don’t have the competencies to practice expert palliative care if they don’t seek them out,” she says. But the opportunities are increasing, with growing palliative care fellowship opportunities nationwide.

Two hospitalists at Chandler Regional Medical Center in Chandler, AZ, are among the 4 physicians who serve on that facility’s 12-member interdisciplinary palliative care team, attending weekly team meetings to review active cases and brainstorm program development. Both have attended national palliative care conferences, reports the palliative care service’s nurse practitioner, Donna Nolde. The service consulted on 89 patients in March, and about 70% of those referrals came from hospitalists.

“As hospitalists, we often deal with issues of death and dying,” especially when working in the ICU or with referring oncologists, notes Chandler’s Mahmood Shahlapour. “We can sometimes step back and see the big picture when other doctors have trouble letting go.” Dr. Shahlapour believes palliative care is a logical extension of good internal medicine and will eventually become a bigger part of the training of internists.

An atypical path to palliative care is that of Glenda Hickman, MD, who was a hospitalist for the Denver, CO–based HealthONE system until one of the system’s hospitals asked her to take on the role of freelance palliative care consultant. Hickman, who also works part-time for Hospice of Metro Denver as a team medical director and picks up lecturing and teaching assignments, accepts consultations from 3 HealthONE hospitals and bills third-party payers for her consultations. Her husband is office manager and biller for her home-based business, and she carries a cell phone and pager to promptly answer referrals.

“I had a reputation for the touchy-feely aspects of medicine at the hospitals where I worked,” Dr. Hickman relates. “Dying patients would often get referred to me.” Based on her interests, Dr. Hickman sought training in palliative care, but she found it difficult to juggle with her full-time job as a hospitalist. “The heart of palliative care in a hospital is talking with patients and families. These conversations take a long time,” she says. When the hospital asked for her help in meeting its JCAHO requirements in pain management and palliative care, Dr. Hickman was willing to explore a model for how she could hang out a shingle as a solo practitioner.

Business is growing, although the workload fluctuates widely. However, while Dr. Hickman works alongside social workers and chaplains at the hospitals, the biggest drawback has been the lack of a formal, interdisciplinary team. “This is high-maintenance, high-emotion work. It can be a big drain, and I don’t have a designated team with which to share the burden. My goal is to run a full palliative care team for the hospital,” she says, and there are signs that HealthONE eventually may move in that direction.

“It’s not that hospitalists can’t do palliative care. I did. I was so drawn to it and to trying to do it right, which meant I was trying to do 2 jobs at once,” she adds. Hospitalists can also participate by recognizing when their patients need the extra attention of a palliative care specialist. “Identifying who those patients are is a huge skill by itself.”

Resources for Getting Started in Palliative Care

The Center to Advance Palliative Care (CAPC) at Mount Sinai School of Medicine in New York City offers a comprehensive national resource for palliative care development in hospitals, including how to make the financial case. Its next national seminar is October 17 to 19 in San Diego, CA. CAPC also supports 6 regional Palliative Care Leadership Centers, including one with a hospitalist emphasis at the University of California-San Francisco, scheduled to run through June 2006. For more information on CAPC’s resources and leadership centers, call 202-201-2670 or visit www.capc.org.

Larry Beresford can be contacted at [email protected].

Other Helpful Resources

• For information on the Education in Palliative and End-of-Life Care (EPEC) curriculum, visit www.epec.net.
• The American Board of Hospice and Palliative Medicine will offer its next specialty certifying examination in November of 2005. For eligibility or other questions, call 301-439-8001 or visit www.abhpm.org.
• The American Association of Hospice and Palliative Medicine offers education and training resources, including an annual assembly scheduled for February 8 to 11, 2006, in Nashville, TN; visit www.aahpm.org.
• Harvard’s Center for Palliative Care offers a 2-week intensive training course, with an emphasis on teaching, in April and November every year. For information, call 617-724-9509, send email to [email protected], or visit www.hms.harvard.edu/cdi/pallcare/.
• The Veterans Administration also offers palliative care resources, fellowship opportunities and other information; visit www.hospice.va.gov.

Howard Epstein, a hospitalist at Regions Hospital in St. Paul, MN, spent nearly 2 years planning an inpatient palliative care consultation service for Regions before its launch in January of this year. A multidisciplinary advisory committee met monthly to help with the planning, and Dr. Epstein, the embryonic program’s medical director, went before the hospital’s administration to make the clinical and financial case for supporting it.

“What we’re trying to do is to take the basic interdisciplinary approach pioneered in hospice and move it upstream,” to help relieve suffering in seriously ill patients before they need or qualify for hospice care, he explains. “I just knew I wanted to incorporate it into a hospitalist model,” and into the Hospitalist Services Division’s weekly block schedule.

After the service was launched, it became clear that the schedule did not allow for the significant time commitment required to do palliative care, so a new approach is planned for July. Dr. Epstein and 6 other hospitalists participating in the palliative care service will divide up weekly blocks of time. Half of their duties while on service will be devoted to palliative care and the other half to covering 1 hospital unit as a hospitalist, rather than the usual 2 units for hospitalists at Regions.

The palliative care service at Regions, which includes a half-time chaplain and social worker and a full-time nurse practitioner, responds to consultation requests by doctors and nurses from all of the hospital’s adult services. The service also admits patients from HealthPartners’ affiliated hospice program when they are hospitalized at Regions for short-term symptom management or respite care.

Key to long-term success lies in documenting improved clinical outcomes, patient, family, and provider satisfaction, financial savings, and enhanced patient throughput. “I’m optimistic we’ll be able to demonstrate significant value, but if we can’t, we’ll be hard-pressed to get continued support,” he says. This challenge, he adds, is similar to what the hospitalist service at Regions faced when it was launched in 1998.

Palliative care is not a new concept in medicine, but it has enjoyed dramatic growth in recent years. The American Hospital Association estimates that 17% of community hospitals and 26% of academic teaching hospitals in the United States now have either a palliative care consultation service or a dedicated unit, although the former is more common because it can be established with a smaller fiscal outlay.

Palliative care aims to relieve suffering, broadly defined, for patients living with chronic, advanced illnesses. State-of-the-art pain management is a major emphasis for the interdisciplinary palliative care team, but so are addressing the patient and family’s emotional, psychological and spiritual concerns related to the illness and offering guidance for making informed treatment decisions that reflect their values and goals for care. Palliative care services generally target all patients with advanced illness from the point of diagnosis, simultaneous with any other medical treatment regimens.

Two Medical Fields Growing Together

“I believe hospitalist practices and palliative care services are of necessity growing closer together,” says Susan Block, codirector of the Harvard Medical School Center for Palliative Care in Boston, MA. The Harvard Center provides intensive palliative care training for clinicians who also have an interest in teaching.

“If you run a palliative care consult service or a palliative care unit, you are operating much like a hospitalist, with a focus on hospital systems and workload issues, communication, and getting people out of the hospital,” Dr. Block says. At the same time, most hospitalists deal with end-of-life issues and the challenges of relieving symptoms such as pain, delirium, or anxiety every day, whether they view their role in those terms or not.

Stephanie Grossman, a hospitalist at Emory Healthcare in Atlanta, GA, says she discovered personal satisfaction as a young physician in having meaningful conversations about care goals with seriously ill patients and leading family conferences, despite the time pressures of the job. The head of the hospital medicine service at Emory, Mark Williams, MD, told Dr. Grossman there was a name for what she enjoyed doing: palliative care. He encouraged her, along with colleague Melissa Mahoney, to obtain additional training in developing such a program, starting with a 2003 conference in San Diego sponsored by the Center to Advance Palliative Care.

“I came back from San Diego feeling swept away by how it really was possible to develop a financially feasible program,” says Dr. Grossman. Back at Emory, she and Dr. Mahoney joined a palliative care task force formed by Dr. Williams, with representatives from geriatrics, nursing, social work, chaplaincy, finance, and administration. This group provided input for a business plan for the palliative care service that will start in September at Emory Crawford Long and Emory University hospitals.

The 2 hospitalists, who have become certified in palliative medicine, will divide a full-time position as codirectors of the inpatient palliative care service in alternating monthly blocks, along with additional teaching responsibilities. Their 4-year plan is to add additional staffing as the program grows and to work with a geriatrician to develop a palliative care fellowship program. The palliative care team, including a nurse, social worker, and chaplain, will conduct daily palliative care rounds and biweekly interdisciplinary case conferences at the 2 hospitals.

“We have a nurse practitioner involved to help us coordinate between the 2 sites. We’ll go to various departments and do some grand rounds to introduce and market the program,” Dr. Grossman notes. In addition to practicing a style of medicine that offers deeper personal interactions with patients, she is excited to be part of creating a new program. However, she emphasizes the importance of having an executive champion within the hospital who understands financing, institutional politics, and how to recruit other champions. “We’ve been lucky to enjoy the support of Dr. Williams and [Emory Chief Operating Officer] Pete Basler. Dr. Mahoney and I have been working with hospitalists for several years, but our work has all been clinical,” she says.

Another challenge for hospitalists interested in pursuing palliative care include the need to make sure their new responsibilities are not just an add-on to a full-time job. The hospital needs to commit resources for planning and implementing a palliative care program, including a percentage of the hospitalist’s time, Dr. Block says. “Zero FTEs is not viable in the long run,” she adds.

Physician billing for palliative care consults can help offset the costs of running a service, but it is unlikely to break even on billing alone, says Eva Chittenden, a hospitalist and palliative care physician at the University of California-San Francisco, which has operated a palliative care service since 1999. Dr. Chittenden is also part of the Palliative Care Leadership Center at UCSF, which offers 2-day intensive training programs 4 times a year for hospital teams that want to start or strengthen inpatient palliative care services.

In most cases, palliative care requires financial support from the hospital, although it’s not difficult to justify that support by showing cost avoidance, reduced lengths of stay, and improved clinical outcomes, with the help of tools developed by the Center to Advance Palliative Care, Dr. Chittenden says. Program development also challenges the hospitalist’s leadership and marketing skills.

A Process of Growing Involvement

“What often happens with hospitalists is that they start out exploring palliative care, and it becomes very compelling,” Dr. Block adds. “The more competent you get at it, the more compelling it becomes. They find deeper meaning in their work. And then they’re hooked.”

A hospitalist can seek additional training and then incorporate palliative care tools, concepts, and perspectives into his or her daily work. An interest in palliative care may lead to involvement with the hospital ethics committee, a seat on a palliative care advisory committee, or a role in standards or protocol development, as well as pursuit of specialty certification in hospice and palliative medicine.

Although hospitalists may be obvious candidates to participate in more formal palliative care program development, “incorporating palliative care into a routine hospitalist practice is not a trivial thing,” Dr. Block adds. For starters, it requires additional training. “Most hospitalists don’t have the competencies to practice expert palliative care if they don’t seek them out,” she says. But the opportunities are increasing, with growing palliative care fellowship opportunities nationwide.

Two hospitalists at Chandler Regional Medical Center in Chandler, AZ, are among the 4 physicians who serve on that facility’s 12-member interdisciplinary palliative care team, attending weekly team meetings to review active cases and brainstorm program development. Both have attended national palliative care conferences, reports the palliative care service’s nurse practitioner, Donna Nolde. The service consulted on 89 patients in March, and about 70% of those referrals came from hospitalists.

“As hospitalists, we often deal with issues of death and dying,” especially when working in the ICU or with referring oncologists, notes Chandler’s Mahmood Shahlapour. “We can sometimes step back and see the big picture when other doctors have trouble letting go.” Dr. Shahlapour believes palliative care is a logical extension of good internal medicine and will eventually become a bigger part of the training of internists.

An atypical path to palliative care is that of Glenda Hickman, MD, who was a hospitalist for the Denver, CO–based HealthONE system until one of the system’s hospitals asked her to take on the role of freelance palliative care consultant. Hickman, who also works part-time for Hospice of Metro Denver as a team medical director and picks up lecturing and teaching assignments, accepts consultations from 3 HealthONE hospitals and bills third-party payers for her consultations. Her husband is office manager and biller for her home-based business, and she carries a cell phone and pager to promptly answer referrals.

“I had a reputation for the touchy-feely aspects of medicine at the hospitals where I worked,” Dr. Hickman relates. “Dying patients would often get referred to me.” Based on her interests, Dr. Hickman sought training in palliative care, but she found it difficult to juggle with her full-time job as a hospitalist. “The heart of palliative care in a hospital is talking with patients and families. These conversations take a long time,” she says. When the hospital asked for her help in meeting its JCAHO requirements in pain management and palliative care, Dr. Hickman was willing to explore a model for how she could hang out a shingle as a solo practitioner.

Business is growing, although the workload fluctuates widely. However, while Dr. Hickman works alongside social workers and chaplains at the hospitals, the biggest drawback has been the lack of a formal, interdisciplinary team. “This is high-maintenance, high-emotion work. It can be a big drain, and I don’t have a designated team with which to share the burden. My goal is to run a full palliative care team for the hospital,” she says, and there are signs that HealthONE eventually may move in that direction.

“It’s not that hospitalists can’t do palliative care. I did. I was so drawn to it and to trying to do it right, which meant I was trying to do 2 jobs at once,” she adds. Hospitalists can also participate by recognizing when their patients need the extra attention of a palliative care specialist. “Identifying who those patients are is a huge skill by itself.”

Resources for Getting Started in Palliative Care

The Center to Advance Palliative Care (CAPC) at Mount Sinai School of Medicine in New York City offers a comprehensive national resource for palliative care development in hospitals, including how to make the financial case. Its next national seminar is October 17 to 19 in San Diego, CA. CAPC also supports 6 regional Palliative Care Leadership Centers, including one with a hospitalist emphasis at the University of California-San Francisco, scheduled to run through June 2006. For more information on CAPC’s resources and leadership centers, call 202-201-2670 or visit www.capc.org.

Larry Beresford can be contacted at [email protected].

Other Helpful Resources

• For information on the Education in Palliative and End-of-Life Care (EPEC) curriculum, visit www.epec.net.
• The American Board of Hospice and Palliative Medicine will offer its next specialty certifying examination in November of 2005. For eligibility or other questions, call 301-439-8001 or visit www.abhpm.org.
• The American Association of Hospice and Palliative Medicine offers education and training resources, including an annual assembly scheduled for February 8 to 11, 2006, in Nashville, TN; visit www.aahpm.org.
• Harvard’s Center for Palliative Care offers a 2-week intensive training course, with an emphasis on teaching, in April and November every year. For information, call 617-724-9509, send email to [email protected], or visit www.hms.harvard.edu/cdi/pallcare/.
• The Veterans Administration also offers palliative care resources, fellowship opportunities and other information; visit www.hospice.va.gov.

Howard Epstein, a hospitalist at Regions Hospital in St. Paul, MN, spent nearly 2 years planning an inpatient palliative care consultation service for Regions before its launch in January of this year. A multidisciplinary advisory committee met monthly to help with the planning, and Dr. Epstein, the embryonic program’s medical director, went before the hospital’s administration to make the clinical and financial case for supporting it.

“What we’re trying to do is to take the basic interdisciplinary approach pioneered in hospice and move it upstream,” to help relieve suffering in seriously ill patients before they need or qualify for hospice care, he explains. “I just knew I wanted to incorporate it into a hospitalist model,” and into the Hospitalist Services Division’s weekly block schedule.

After the service was launched, it became clear that the schedule did not allow for the significant time commitment required to do palliative care, so a new approach is planned for July. Dr. Epstein and 6 other hospitalists participating in the palliative care service will divide up weekly blocks of time. Half of their duties while on service will be devoted to palliative care and the other half to covering 1 hospital unit as a hospitalist, rather than the usual 2 units for hospitalists at Regions.

The palliative care service at Regions, which includes a half-time chaplain and social worker and a full-time nurse practitioner, responds to consultation requests by doctors and nurses from all of the hospital’s adult services. The service also admits patients from HealthPartners’ affiliated hospice program when they are hospitalized at Regions for short-term symptom management or respite care.

Key to long-term success lies in documenting improved clinical outcomes, patient, family, and provider satisfaction, financial savings, and enhanced patient throughput. “I’m optimistic we’ll be able to demonstrate significant value, but if we can’t, we’ll be hard-pressed to get continued support,” he says. This challenge, he adds, is similar to what the hospitalist service at Regions faced when it was launched in 1998.

Palliative care is not a new concept in medicine, but it has enjoyed dramatic growth in recent years. The American Hospital Association estimates that 17% of community hospitals and 26% of academic teaching hospitals in the United States now have either a palliative care consultation service or a dedicated unit, although the former is more common because it can be established with a smaller fiscal outlay.

Palliative care aims to relieve suffering, broadly defined, for patients living with chronic, advanced illnesses. State-of-the-art pain management is a major emphasis for the interdisciplinary palliative care team, but so are addressing the patient and family’s emotional, psychological and spiritual concerns related to the illness and offering guidance for making informed treatment decisions that reflect their values and goals for care. Palliative care services generally target all patients with advanced illness from the point of diagnosis, simultaneous with any other medical treatment regimens.

Two Medical Fields Growing Together

“I believe hospitalist practices and palliative care services are of necessity growing closer together,” says Susan Block, codirector of the Harvard Medical School Center for Palliative Care in Boston, MA. The Harvard Center provides intensive palliative care training for clinicians who also have an interest in teaching.

“If you run a palliative care consult service or a palliative care unit, you are operating much like a hospitalist, with a focus on hospital systems and workload issues, communication, and getting people out of the hospital,” Dr. Block says. At the same time, most hospitalists deal with end-of-life issues and the challenges of relieving symptoms such as pain, delirium, or anxiety every day, whether they view their role in those terms or not.

Stephanie Grossman, a hospitalist at Emory Healthcare in Atlanta, GA, says she discovered personal satisfaction as a young physician in having meaningful conversations about care goals with seriously ill patients and leading family conferences, despite the time pressures of the job. The head of the hospital medicine service at Emory, Mark Williams, MD, told Dr. Grossman there was a name for what she enjoyed doing: palliative care. He encouraged her, along with colleague Melissa Mahoney, to obtain additional training in developing such a program, starting with a 2003 conference in San Diego sponsored by the Center to Advance Palliative Care.

“I came back from San Diego feeling swept away by how it really was possible to develop a financially feasible program,” says Dr. Grossman. Back at Emory, she and Dr. Mahoney joined a palliative care task force formed by Dr. Williams, with representatives from geriatrics, nursing, social work, chaplaincy, finance, and administration. This group provided input for a business plan for the palliative care service that will start in September at Emory Crawford Long and Emory University hospitals.

The 2 hospitalists, who have become certified in palliative medicine, will divide a full-time position as codirectors of the inpatient palliative care service in alternating monthly blocks, along with additional teaching responsibilities. Their 4-year plan is to add additional staffing as the program grows and to work with a geriatrician to develop a palliative care fellowship program. The palliative care team, including a nurse, social worker, and chaplain, will conduct daily palliative care rounds and biweekly interdisciplinary case conferences at the 2 hospitals.

“We have a nurse practitioner involved to help us coordinate between the 2 sites. We’ll go to various departments and do some grand rounds to introduce and market the program,” Dr. Grossman notes. In addition to practicing a style of medicine that offers deeper personal interactions with patients, she is excited to be part of creating a new program. However, she emphasizes the importance of having an executive champion within the hospital who understands financing, institutional politics, and how to recruit other champions. “We’ve been lucky to enjoy the support of Dr. Williams and [Emory Chief Operating Officer] Pete Basler. Dr. Mahoney and I have been working with hospitalists for several years, but our work has all been clinical,” she says.

Another challenge for hospitalists interested in pursuing palliative care include the need to make sure their new responsibilities are not just an add-on to a full-time job. The hospital needs to commit resources for planning and implementing a palliative care program, including a percentage of the hospitalist’s time, Dr. Block says. “Zero FTEs is not viable in the long run,” she adds.

Physician billing for palliative care consults can help offset the costs of running a service, but it is unlikely to break even on billing alone, says Eva Chittenden, a hospitalist and palliative care physician at the University of California-San Francisco, which has operated a palliative care service since 1999. Dr. Chittenden is also part of the Palliative Care Leadership Center at UCSF, which offers 2-day intensive training programs 4 times a year for hospital teams that want to start or strengthen inpatient palliative care services.

In most cases, palliative care requires financial support from the hospital, although it’s not difficult to justify that support by showing cost avoidance, reduced lengths of stay, and improved clinical outcomes, with the help of tools developed by the Center to Advance Palliative Care, Dr. Chittenden says. Program development also challenges the hospitalist’s leadership and marketing skills.

A Process of Growing Involvement

“What often happens with hospitalists is that they start out exploring palliative care, and it becomes very compelling,” Dr. Block adds. “The more competent you get at it, the more compelling it becomes. They find deeper meaning in their work. And then they’re hooked.”

A hospitalist can seek additional training and then incorporate palliative care tools, concepts, and perspectives into his or her daily work. An interest in palliative care may lead to involvement with the hospital ethics committee, a seat on a palliative care advisory committee, or a role in standards or protocol development, as well as pursuit of specialty certification in hospice and palliative medicine.

Although hospitalists may be obvious candidates to participate in more formal palliative care program development, “incorporating palliative care into a routine hospitalist practice is not a trivial thing,” Dr. Block adds. For starters, it requires additional training. “Most hospitalists don’t have the competencies to practice expert palliative care if they don’t seek them out,” she says. But the opportunities are increasing, with growing palliative care fellowship opportunities nationwide.

Two hospitalists at Chandler Regional Medical Center in Chandler, AZ, are among the 4 physicians who serve on that facility’s 12-member interdisciplinary palliative care team, attending weekly team meetings to review active cases and brainstorm program development. Both have attended national palliative care conferences, reports the palliative care service’s nurse practitioner, Donna Nolde. The service consulted on 89 patients in March, and about 70% of those referrals came from hospitalists.

“As hospitalists, we often deal with issues of death and dying,” especially when working in the ICU or with referring oncologists, notes Chandler’s Mahmood Shahlapour. “We can sometimes step back and see the big picture when other doctors have trouble letting go.” Dr. Shahlapour believes palliative care is a logical extension of good internal medicine and will eventually become a bigger part of the training of internists.

An atypical path to palliative care is that of Glenda Hickman, MD, who was a hospitalist for the Denver, CO–based HealthONE system until one of the system’s hospitals asked her to take on the role of freelance palliative care consultant. Hickman, who also works part-time for Hospice of Metro Denver as a team medical director and picks up lecturing and teaching assignments, accepts consultations from 3 HealthONE hospitals and bills third-party payers for her consultations. Her husband is office manager and biller for her home-based business, and she carries a cell phone and pager to promptly answer referrals.

“I had a reputation for the touchy-feely aspects of medicine at the hospitals where I worked,” Dr. Hickman relates. “Dying patients would often get referred to me.” Based on her interests, Dr. Hickman sought training in palliative care, but she found it difficult to juggle with her full-time job as a hospitalist. “The heart of palliative care in a hospital is talking with patients and families. These conversations take a long time,” she says. When the hospital asked for her help in meeting its JCAHO requirements in pain management and palliative care, Dr. Hickman was willing to explore a model for how she could hang out a shingle as a solo practitioner.

Business is growing, although the workload fluctuates widely. However, while Dr. Hickman works alongside social workers and chaplains at the hospitals, the biggest drawback has been the lack of a formal, interdisciplinary team. “This is high-maintenance, high-emotion work. It can be a big drain, and I don’t have a designated team with which to share the burden. My goal is to run a full palliative care team for the hospital,” she says, and there are signs that HealthONE eventually may move in that direction.

“It’s not that hospitalists can’t do palliative care. I did. I was so drawn to it and to trying to do it right, which meant I was trying to do 2 jobs at once,” she adds. Hospitalists can also participate by recognizing when their patients need the extra attention of a palliative care specialist. “Identifying who those patients are is a huge skill by itself.”

Resources for Getting Started in Palliative Care

The Center to Advance Palliative Care (CAPC) at Mount Sinai School of Medicine in New York City offers a comprehensive national resource for palliative care development in hospitals, including how to make the financial case. Its next national seminar is October 17 to 19 in San Diego, CA. CAPC also supports 6 regional Palliative Care Leadership Centers, including one with a hospitalist emphasis at the University of California-San Francisco, scheduled to run through June 2006. For more information on CAPC’s resources and leadership centers, call 202-201-2670 or visit www.capc.org.

Larry Beresford can be contacted at [email protected].

Other Helpful Resources

• For information on the Education in Palliative and End-of-Life Care (EPEC) curriculum, visit www.epec.net.
• The American Board of Hospice and Palliative Medicine will offer its next specialty certifying examination in November of 2005. For eligibility or other questions, call 301-439-8001 or visit www.abhpm.org.
• The American Association of Hospice and Palliative Medicine offers education and training resources, including an annual assembly scheduled for February 8 to 11, 2006, in Nashville, TN; visit www.aahpm.org.
• Harvard’s Center for Palliative Care offers a 2-week intensive training course, with an emphasis on teaching, in April and November every year. For information, call 617-724-9509, send email to [email protected], or visit www.hms.harvard.edu/cdi/pallcare/.
• The Veterans Administration also offers palliative care resources, fellowship opportunities and other information; visit www.hospice.va.gov.