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Contextual influences of trainee characteristics and daily workload on trainee learning preferences
We previously identified key domains of attending attributes for successful rounds1 and adapted them to represent the trainees’ perspective: Teaching Process (eg, sharing decision-making process, physical exam skills), Learning Environment (eg, being approachable, respectful), Role Modeling (eg, teaching by example, bedside manner), and Team Management (eg, efficiency, providing autonomy). Though all domains are necessary, the relative importance may change in response to external pressures. Inpatient service demands and time constraints fluctuate daily due to patient admissions and discharges, educational conference schedules, and concurrent outpatient clinic responsibilities.2–4 Furthermore, the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour rules placed greater time pressure on inpatient ward attending rounds.5 It is plausible that these pressures affect trainees’ needs and priorities during rounds.
Therefore, we sought to refine our understanding of the learners’ needs during ward rounds. Because we were interested in the contextual influences of trainee characteristics and workload on their preferences, we used the principles of ecological momentary assessment (EMA) to design a novel system to assess daily changes in trainee priorities and associated workload.
METHODS
Design, Participants, and Setting
In a prospective observational study, we assessed trainee priorities during inpatient rounds. Participants included third- and fourth-year medical students in the University of Alabama at Birmingham (UAB) School of Medicine (Birmingham campus) and residents in the Tinsley Harrison Internal Medicine Residency Training Program assigned to inpatient general medicine ward services from September 2010 to February 2011 (except from December 20, 2010, to January 3, 2011). Three training sites were included in this study: UAB Hospital (>1000-bed, university-based hospital), Birmingham Veterans Affairs Medical Center (300-bed), and Cooper Green Hospital (40-bed county hospital). Each site housed 4 or 5 general medicine ward teams, composed of 1–3 medical students (third or fourth year), 2 first-year residents, 1 upper level resident (postgraduate year 2–4), and 1 attending physician.
Trainees were recruited to participate via e-mail and verbal announcements during program conferences. Participation was voluntary and responses were confidential. As an incentive, the team submitting the highest number of cards per site each month received 1 free lunch. Institutional review boards of all 3 participating hospitals approved this study.
Assessment
Our original domains of attending rounds were derived from groupings and ratings of specific teaching characteristics by attending physicians, residents, and students.1 However, because our goal was to understand the learners’ perspective of successful ward rounds, we revised these domains by limiting the algorithm to data on groupings and ratings by residents and students only. This process resulted in the domains used in this study (Appendix).
We used EMA principles to create a novel system to assess daily variation in trainees’ prioritization of these domains and workload.6,7 EMA-derived assessment tools collect data frequently (several times per week, up to multiple times per day) to identify time-sensitive fluctuations. We designed a pocket-sized daily assessment card for trainees to complete each day after rounds (Figure 1). Trainees were asked to indicate the most important domain for successful ward rounds to them that day and provide individual characteristics (ie, sex and training level) and data on factors we hypothesized were related to perceived work load (ie, patient census, day of call cycle, and number of team members absent on rounds that day). We anticipated the Expectations domain would not be responsive to daily changes in workload because expectations are usually set once on the first day of the rotation, and thus we did not include this domain in our final assessment tool. Assessment cards and locked receptacles were kept in team workrooms for ease of accessibility; cards were collected twice monthly. All data were anonymous.
Analysis
Our unit of analysis was the EMA card. We examined associations between daily domain priority with respondent demographics and workload information using Pearson’s chi-squared analyses, adjusted for clustering effects by team. α was set at 0.05. All analyses were performed by using Stata 13.0 (Stata Statistical Software: Release 13; College Station, TX).
RESULTS
Sex and training level were associated with prioritization of teaching domains. Male trainees were more likely to choose Team Management (P = 0.01) or Teaching Process (P = 0.04) as their preferred domain. Medical students valued Teaching Process 42% of the time, compared with 23% for interns and 21% for upper level residents (P = 0.005). The opposite trend emerged for Team Management: as training level increased, the importance of Team Management increased (P < 0.001). There were no significant trends by training level for the Role Modeling and Learning Environment domains.
Domain priority was also associated with workload characteristics. On post-call days, Team Management (P < 0.001) was more likely to be selected as the most important domain, but on other days, Teaching Process (P = 0.005) was more often selected (Figure 2). Trainees also selected Team Management as the most important domain with an increasing number of team members absent (P = 0.001), and as the teams’ overall patient census increased (P < 0.001). The Learning Environment and Role Modeling domains’ importance did not vary by call-day or patient census.
DISCUSSION
We used a novel approach to assess contextual factors affecting trainee prioritization of 4 domains that contribute to successful inpatient internal medicine attending rounds. We found training level and workload demands were associated with prioritization of teaching domains. Prioritization of Teaching Process, exemplified by setting aside time to teach, demonstrating physical exam skills, and clear delineation of the attending’s thought process, was inversely associated with training level. On the days with highest workload, Team Management was most likely to be prioritized. Our findings suggest that attending physicians should consider adapting rounding style based on team members’ training levels and workload.
Prior work has described teaching and rounding styles, influences, and priorities in response to workload from the attending physician’s perspective,8–11 and our study extends these reports by providing the complementary perspective of trainees. On days with high workload, trainees prefer the Team Management domain, characterized by organized and efficient rounds, agreement on a clear and consistent plan of care, and being allowed independence and time during rounds to meet other responsibilities.1 These findings support an “empowerment style,” defined by Goldszmidt et al. as using integrated teaching and oversight strategies to support trainees’ progressive independence.9 Though some attending physicians report shifting to a more direct patient care style on days with a high patient census,9 our results suggest that learners instead prefer more independence, being empowered to perform more direct care. While there is an increasing pressure to heighten attending supervision due to concerns about patient safety, restricted work hours, and litigation,12 trainees value being part of the care process and being included as integral members of the care team, which may actually mitigate patient safety risks.8
Our results are consistent with prior studies, reporting that learners at different levels of training have different instructional needs: medical students seek more teaching, and senior residents sought an efficient leader.13,14 Taken together, these studies suggest that attending physicians should tailor rounds to the level of the trainee. For example, it may be beneficial for the attending physician to spend time outside of rounds with students to teach medical knowledge. During rounds, the entire group benefits most from modeling clinical reasoning, discussing new medical evidence, and demonstrating communication skills and leadership.
Our study has limitations. Though our study was performed before the 2011 ACGME duty hour restrictions,5 our results are likely of greater importance and relevance, as our findings ultimately highlight the competing demands of time vs duty. Also, while our study was performed at a single institution, potentially limiting generalizability, we included 3 types of training hospitals, a university, veterans and a county hospital, and found no differences between sites. Additionally, we collected over 1,000 cards over the course of 6 months, assessing rounds of over 50 different attending physicians, suggesting broader applicability. Our overall response rate was low, a typical signal for respondent bias, but because we collected daily assessments, standard interpretation of response rates referring to a one-time survey do not apply.15 We believe we achieved an adequate sample, as the majority of teams participated, the respondent demographics were proportional to the base population eligible to participate, and we received a similar number of cards on all months. Finally, although we were unable to account for clustering effects by individual respondents because response cards were anonymous, we adjusted for clustering effects by team.
Attending physicians may use our findings to adapt teaching techniques to appeal to specific training levels and to external pressures during teaching rounds. Focusing and investing time in teaching medical knowledge and clinical reasoning tailored to each level of learner is paramount on most days. However, days with a high workload may require emphasis on delegating clear, rational treatment plans, when learners are less receptive to traditional didactic methods.
Disclosure
An abstract based on the current analysis was presented at the Society of General Internal Medicine 34th Annual Meeting, April 2011, Phoenix, AZ. Dr. Brita Roy is supported by grant number K12HS023000 from the Agency for Healthcare Research and Quality. The authors have no conflicts to disclose. The opinions expressed in this article are those of the authors alone and do not reflect the views of the Department of Veterans Affairs or the Agency for Healthcare Research and Quality.
1. Roy B, Salanitro AH, Willett L, et al. Using cognitive mapping to identify attributes contributing to successful ward-attending rounds -- a resident and student perspective. J Gen Intern Med. 2010;25(S3):2. PubMed
2. Ben-Menachem T, Estrada C, Young MJ, et al. Balancing service and education: improving internal medicine residencies in the managed care era. Am J Med. 1996;100(2):224–229. PubMed
3. Drolet BC, Bishop KD. Unintended consequences of duty hours regulation. Acad Med. 2012;87(6):680. PubMed
4. Drolet BC, Spalluto LB, Fischer SA. Residents’ perspectives on ACGME regulation of supervision and duty hours--a national survey. N Engl J Med. 2010;363(23):e34. PubMed
5. Nasca TJ, Day SH, Amis ES, Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. PubMed
6. Shiffman S, Stone AA, Hufford MR. Ecological momentary assessment. Annu Rev Clin Psychol. 2008;4:1–32. PubMed
7. Moskowitz DS, Young SN. Ecological momentary assessment: what it is and why it is a method of the future in clinical psychopharmacology. J Psychiatry Neurosci. 2006;31(1):13–20. PubMed
8. Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169–173. PubMed
9. Goldszmidt M, Faden L, Dornan T, van Merriënboer J, Bordage G, Lingard L. Attending physician variability: a model of four supervisory styles. Acad Med. 2015;90(11):1541–1546. PubMed
10. Kennedy TJ, Lingard L, Baker GR, Kitchen L, Regehr G. Clinical oversight: conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22(8):1080–1085. PubMed
11. Irby DM. How attending physicians make instructional decisions when conducting teaching rounds. Acad Med. 1992;67(10):630–638. PubMed
12. Kennedy TJ, Regehr G, Baker GR, Lingard LA. Progressive independence in clinical training: a tradition worth defending? Acad Med. 2005;80(10):S106–S111. PubMed
13. Tariq M, Motiwala A, Ali SU, Riaz M, Awan S, Akhter J. The learners’ perspective on internal medicine ward rounds: a cross-sectional study. BMC Med Educ. 2010;10:53. PubMed
14. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12):e644–e650. PubMed
15. Stone AA, Shiffman S. Capturing momentary, self-report data: A proposal for reporting guidelines. Ann Behav Med. 2002;24(3):236–243. PubMed
We previously identified key domains of attending attributes for successful rounds1 and adapted them to represent the trainees’ perspective: Teaching Process (eg, sharing decision-making process, physical exam skills), Learning Environment (eg, being approachable, respectful), Role Modeling (eg, teaching by example, bedside manner), and Team Management (eg, efficiency, providing autonomy). Though all domains are necessary, the relative importance may change in response to external pressures. Inpatient service demands and time constraints fluctuate daily due to patient admissions and discharges, educational conference schedules, and concurrent outpatient clinic responsibilities.2–4 Furthermore, the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour rules placed greater time pressure on inpatient ward attending rounds.5 It is plausible that these pressures affect trainees’ needs and priorities during rounds.
Therefore, we sought to refine our understanding of the learners’ needs during ward rounds. Because we were interested in the contextual influences of trainee characteristics and workload on their preferences, we used the principles of ecological momentary assessment (EMA) to design a novel system to assess daily changes in trainee priorities and associated workload.
METHODS
Design, Participants, and Setting
In a prospective observational study, we assessed trainee priorities during inpatient rounds. Participants included third- and fourth-year medical students in the University of Alabama at Birmingham (UAB) School of Medicine (Birmingham campus) and residents in the Tinsley Harrison Internal Medicine Residency Training Program assigned to inpatient general medicine ward services from September 2010 to February 2011 (except from December 20, 2010, to January 3, 2011). Three training sites were included in this study: UAB Hospital (>1000-bed, university-based hospital), Birmingham Veterans Affairs Medical Center (300-bed), and Cooper Green Hospital (40-bed county hospital). Each site housed 4 or 5 general medicine ward teams, composed of 1–3 medical students (third or fourth year), 2 first-year residents, 1 upper level resident (postgraduate year 2–4), and 1 attending physician.
Trainees were recruited to participate via e-mail and verbal announcements during program conferences. Participation was voluntary and responses were confidential. As an incentive, the team submitting the highest number of cards per site each month received 1 free lunch. Institutional review boards of all 3 participating hospitals approved this study.
Assessment
Our original domains of attending rounds were derived from groupings and ratings of specific teaching characteristics by attending physicians, residents, and students.1 However, because our goal was to understand the learners’ perspective of successful ward rounds, we revised these domains by limiting the algorithm to data on groupings and ratings by residents and students only. This process resulted in the domains used in this study (Appendix).
We used EMA principles to create a novel system to assess daily variation in trainees’ prioritization of these domains and workload.6,7 EMA-derived assessment tools collect data frequently (several times per week, up to multiple times per day) to identify time-sensitive fluctuations. We designed a pocket-sized daily assessment card for trainees to complete each day after rounds (Figure 1). Trainees were asked to indicate the most important domain for successful ward rounds to them that day and provide individual characteristics (ie, sex and training level) and data on factors we hypothesized were related to perceived work load (ie, patient census, day of call cycle, and number of team members absent on rounds that day). We anticipated the Expectations domain would not be responsive to daily changes in workload because expectations are usually set once on the first day of the rotation, and thus we did not include this domain in our final assessment tool. Assessment cards and locked receptacles were kept in team workrooms for ease of accessibility; cards were collected twice monthly. All data were anonymous.
Analysis
Our unit of analysis was the EMA card. We examined associations between daily domain priority with respondent demographics and workload information using Pearson’s chi-squared analyses, adjusted for clustering effects by team. α was set at 0.05. All analyses were performed by using Stata 13.0 (Stata Statistical Software: Release 13; College Station, TX).
RESULTS
Sex and training level were associated with prioritization of teaching domains. Male trainees were more likely to choose Team Management (P = 0.01) or Teaching Process (P = 0.04) as their preferred domain. Medical students valued Teaching Process 42% of the time, compared with 23% for interns and 21% for upper level residents (P = 0.005). The opposite trend emerged for Team Management: as training level increased, the importance of Team Management increased (P < 0.001). There were no significant trends by training level for the Role Modeling and Learning Environment domains.
Domain priority was also associated with workload characteristics. On post-call days, Team Management (P < 0.001) was more likely to be selected as the most important domain, but on other days, Teaching Process (P = 0.005) was more often selected (Figure 2). Trainees also selected Team Management as the most important domain with an increasing number of team members absent (P = 0.001), and as the teams’ overall patient census increased (P < 0.001). The Learning Environment and Role Modeling domains’ importance did not vary by call-day or patient census.
DISCUSSION
We used a novel approach to assess contextual factors affecting trainee prioritization of 4 domains that contribute to successful inpatient internal medicine attending rounds. We found training level and workload demands were associated with prioritization of teaching domains. Prioritization of Teaching Process, exemplified by setting aside time to teach, demonstrating physical exam skills, and clear delineation of the attending’s thought process, was inversely associated with training level. On the days with highest workload, Team Management was most likely to be prioritized. Our findings suggest that attending physicians should consider adapting rounding style based on team members’ training levels and workload.
Prior work has described teaching and rounding styles, influences, and priorities in response to workload from the attending physician’s perspective,8–11 and our study extends these reports by providing the complementary perspective of trainees. On days with high workload, trainees prefer the Team Management domain, characterized by organized and efficient rounds, agreement on a clear and consistent plan of care, and being allowed independence and time during rounds to meet other responsibilities.1 These findings support an “empowerment style,” defined by Goldszmidt et al. as using integrated teaching and oversight strategies to support trainees’ progressive independence.9 Though some attending physicians report shifting to a more direct patient care style on days with a high patient census,9 our results suggest that learners instead prefer more independence, being empowered to perform more direct care. While there is an increasing pressure to heighten attending supervision due to concerns about patient safety, restricted work hours, and litigation,12 trainees value being part of the care process and being included as integral members of the care team, which may actually mitigate patient safety risks.8
Our results are consistent with prior studies, reporting that learners at different levels of training have different instructional needs: medical students seek more teaching, and senior residents sought an efficient leader.13,14 Taken together, these studies suggest that attending physicians should tailor rounds to the level of the trainee. For example, it may be beneficial for the attending physician to spend time outside of rounds with students to teach medical knowledge. During rounds, the entire group benefits most from modeling clinical reasoning, discussing new medical evidence, and demonstrating communication skills and leadership.
Our study has limitations. Though our study was performed before the 2011 ACGME duty hour restrictions,5 our results are likely of greater importance and relevance, as our findings ultimately highlight the competing demands of time vs duty. Also, while our study was performed at a single institution, potentially limiting generalizability, we included 3 types of training hospitals, a university, veterans and a county hospital, and found no differences between sites. Additionally, we collected over 1,000 cards over the course of 6 months, assessing rounds of over 50 different attending physicians, suggesting broader applicability. Our overall response rate was low, a typical signal for respondent bias, but because we collected daily assessments, standard interpretation of response rates referring to a one-time survey do not apply.15 We believe we achieved an adequate sample, as the majority of teams participated, the respondent demographics were proportional to the base population eligible to participate, and we received a similar number of cards on all months. Finally, although we were unable to account for clustering effects by individual respondents because response cards were anonymous, we adjusted for clustering effects by team.
Attending physicians may use our findings to adapt teaching techniques to appeal to specific training levels and to external pressures during teaching rounds. Focusing and investing time in teaching medical knowledge and clinical reasoning tailored to each level of learner is paramount on most days. However, days with a high workload may require emphasis on delegating clear, rational treatment plans, when learners are less receptive to traditional didactic methods.
Disclosure
An abstract based on the current analysis was presented at the Society of General Internal Medicine 34th Annual Meeting, April 2011, Phoenix, AZ. Dr. Brita Roy is supported by grant number K12HS023000 from the Agency for Healthcare Research and Quality. The authors have no conflicts to disclose. The opinions expressed in this article are those of the authors alone and do not reflect the views of the Department of Veterans Affairs or the Agency for Healthcare Research and Quality.
We previously identified key domains of attending attributes for successful rounds1 and adapted them to represent the trainees’ perspective: Teaching Process (eg, sharing decision-making process, physical exam skills), Learning Environment (eg, being approachable, respectful), Role Modeling (eg, teaching by example, bedside manner), and Team Management (eg, efficiency, providing autonomy). Though all domains are necessary, the relative importance may change in response to external pressures. Inpatient service demands and time constraints fluctuate daily due to patient admissions and discharges, educational conference schedules, and concurrent outpatient clinic responsibilities.2–4 Furthermore, the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour rules placed greater time pressure on inpatient ward attending rounds.5 It is plausible that these pressures affect trainees’ needs and priorities during rounds.
Therefore, we sought to refine our understanding of the learners’ needs during ward rounds. Because we were interested in the contextual influences of trainee characteristics and workload on their preferences, we used the principles of ecological momentary assessment (EMA) to design a novel system to assess daily changes in trainee priorities and associated workload.
METHODS
Design, Participants, and Setting
In a prospective observational study, we assessed trainee priorities during inpatient rounds. Participants included third- and fourth-year medical students in the University of Alabama at Birmingham (UAB) School of Medicine (Birmingham campus) and residents in the Tinsley Harrison Internal Medicine Residency Training Program assigned to inpatient general medicine ward services from September 2010 to February 2011 (except from December 20, 2010, to January 3, 2011). Three training sites were included in this study: UAB Hospital (>1000-bed, university-based hospital), Birmingham Veterans Affairs Medical Center (300-bed), and Cooper Green Hospital (40-bed county hospital). Each site housed 4 or 5 general medicine ward teams, composed of 1–3 medical students (third or fourth year), 2 first-year residents, 1 upper level resident (postgraduate year 2–4), and 1 attending physician.
Trainees were recruited to participate via e-mail and verbal announcements during program conferences. Participation was voluntary and responses were confidential. As an incentive, the team submitting the highest number of cards per site each month received 1 free lunch. Institutional review boards of all 3 participating hospitals approved this study.
Assessment
Our original domains of attending rounds were derived from groupings and ratings of specific teaching characteristics by attending physicians, residents, and students.1 However, because our goal was to understand the learners’ perspective of successful ward rounds, we revised these domains by limiting the algorithm to data on groupings and ratings by residents and students only. This process resulted in the domains used in this study (Appendix).
We used EMA principles to create a novel system to assess daily variation in trainees’ prioritization of these domains and workload.6,7 EMA-derived assessment tools collect data frequently (several times per week, up to multiple times per day) to identify time-sensitive fluctuations. We designed a pocket-sized daily assessment card for trainees to complete each day after rounds (Figure 1). Trainees were asked to indicate the most important domain for successful ward rounds to them that day and provide individual characteristics (ie, sex and training level) and data on factors we hypothesized were related to perceived work load (ie, patient census, day of call cycle, and number of team members absent on rounds that day). We anticipated the Expectations domain would not be responsive to daily changes in workload because expectations are usually set once on the first day of the rotation, and thus we did not include this domain in our final assessment tool. Assessment cards and locked receptacles were kept in team workrooms for ease of accessibility; cards were collected twice monthly. All data were anonymous.
Analysis
Our unit of analysis was the EMA card. We examined associations between daily domain priority with respondent demographics and workload information using Pearson’s chi-squared analyses, adjusted for clustering effects by team. α was set at 0.05. All analyses were performed by using Stata 13.0 (Stata Statistical Software: Release 13; College Station, TX).
RESULTS
Sex and training level were associated with prioritization of teaching domains. Male trainees were more likely to choose Team Management (P = 0.01) or Teaching Process (P = 0.04) as their preferred domain. Medical students valued Teaching Process 42% of the time, compared with 23% for interns and 21% for upper level residents (P = 0.005). The opposite trend emerged for Team Management: as training level increased, the importance of Team Management increased (P < 0.001). There were no significant trends by training level for the Role Modeling and Learning Environment domains.
Domain priority was also associated with workload characteristics. On post-call days, Team Management (P < 0.001) was more likely to be selected as the most important domain, but on other days, Teaching Process (P = 0.005) was more often selected (Figure 2). Trainees also selected Team Management as the most important domain with an increasing number of team members absent (P = 0.001), and as the teams’ overall patient census increased (P < 0.001). The Learning Environment and Role Modeling domains’ importance did not vary by call-day or patient census.
DISCUSSION
We used a novel approach to assess contextual factors affecting trainee prioritization of 4 domains that contribute to successful inpatient internal medicine attending rounds. We found training level and workload demands were associated with prioritization of teaching domains. Prioritization of Teaching Process, exemplified by setting aside time to teach, demonstrating physical exam skills, and clear delineation of the attending’s thought process, was inversely associated with training level. On the days with highest workload, Team Management was most likely to be prioritized. Our findings suggest that attending physicians should consider adapting rounding style based on team members’ training levels and workload.
Prior work has described teaching and rounding styles, influences, and priorities in response to workload from the attending physician’s perspective,8–11 and our study extends these reports by providing the complementary perspective of trainees. On days with high workload, trainees prefer the Team Management domain, characterized by organized and efficient rounds, agreement on a clear and consistent plan of care, and being allowed independence and time during rounds to meet other responsibilities.1 These findings support an “empowerment style,” defined by Goldszmidt et al. as using integrated teaching and oversight strategies to support trainees’ progressive independence.9 Though some attending physicians report shifting to a more direct patient care style on days with a high patient census,9 our results suggest that learners instead prefer more independence, being empowered to perform more direct care. While there is an increasing pressure to heighten attending supervision due to concerns about patient safety, restricted work hours, and litigation,12 trainees value being part of the care process and being included as integral members of the care team, which may actually mitigate patient safety risks.8
Our results are consistent with prior studies, reporting that learners at different levels of training have different instructional needs: medical students seek more teaching, and senior residents sought an efficient leader.13,14 Taken together, these studies suggest that attending physicians should tailor rounds to the level of the trainee. For example, it may be beneficial for the attending physician to spend time outside of rounds with students to teach medical knowledge. During rounds, the entire group benefits most from modeling clinical reasoning, discussing new medical evidence, and demonstrating communication skills and leadership.
Our study has limitations. Though our study was performed before the 2011 ACGME duty hour restrictions,5 our results are likely of greater importance and relevance, as our findings ultimately highlight the competing demands of time vs duty. Also, while our study was performed at a single institution, potentially limiting generalizability, we included 3 types of training hospitals, a university, veterans and a county hospital, and found no differences between sites. Additionally, we collected over 1,000 cards over the course of 6 months, assessing rounds of over 50 different attending physicians, suggesting broader applicability. Our overall response rate was low, a typical signal for respondent bias, but because we collected daily assessments, standard interpretation of response rates referring to a one-time survey do not apply.15 We believe we achieved an adequate sample, as the majority of teams participated, the respondent demographics were proportional to the base population eligible to participate, and we received a similar number of cards on all months. Finally, although we were unable to account for clustering effects by individual respondents because response cards were anonymous, we adjusted for clustering effects by team.
Attending physicians may use our findings to adapt teaching techniques to appeal to specific training levels and to external pressures during teaching rounds. Focusing and investing time in teaching medical knowledge and clinical reasoning tailored to each level of learner is paramount on most days. However, days with a high workload may require emphasis on delegating clear, rational treatment plans, when learners are less receptive to traditional didactic methods.
Disclosure
An abstract based on the current analysis was presented at the Society of General Internal Medicine 34th Annual Meeting, April 2011, Phoenix, AZ. Dr. Brita Roy is supported by grant number K12HS023000 from the Agency for Healthcare Research and Quality. The authors have no conflicts to disclose. The opinions expressed in this article are those of the authors alone and do not reflect the views of the Department of Veterans Affairs or the Agency for Healthcare Research and Quality.
1. Roy B, Salanitro AH, Willett L, et al. Using cognitive mapping to identify attributes contributing to successful ward-attending rounds -- a resident and student perspective. J Gen Intern Med. 2010;25(S3):2. PubMed
2. Ben-Menachem T, Estrada C, Young MJ, et al. Balancing service and education: improving internal medicine residencies in the managed care era. Am J Med. 1996;100(2):224–229. PubMed
3. Drolet BC, Bishop KD. Unintended consequences of duty hours regulation. Acad Med. 2012;87(6):680. PubMed
4. Drolet BC, Spalluto LB, Fischer SA. Residents’ perspectives on ACGME regulation of supervision and duty hours--a national survey. N Engl J Med. 2010;363(23):e34. PubMed
5. Nasca TJ, Day SH, Amis ES, Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. PubMed
6. Shiffman S, Stone AA, Hufford MR. Ecological momentary assessment. Annu Rev Clin Psychol. 2008;4:1–32. PubMed
7. Moskowitz DS, Young SN. Ecological momentary assessment: what it is and why it is a method of the future in clinical psychopharmacology. J Psychiatry Neurosci. 2006;31(1):13–20. PubMed
8. Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169–173. PubMed
9. Goldszmidt M, Faden L, Dornan T, van Merriënboer J, Bordage G, Lingard L. Attending physician variability: a model of four supervisory styles. Acad Med. 2015;90(11):1541–1546. PubMed
10. Kennedy TJ, Lingard L, Baker GR, Kitchen L, Regehr G. Clinical oversight: conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22(8):1080–1085. PubMed
11. Irby DM. How attending physicians make instructional decisions when conducting teaching rounds. Acad Med. 1992;67(10):630–638. PubMed
12. Kennedy TJ, Regehr G, Baker GR, Lingard LA. Progressive independence in clinical training: a tradition worth defending? Acad Med. 2005;80(10):S106–S111. PubMed
13. Tariq M, Motiwala A, Ali SU, Riaz M, Awan S, Akhter J. The learners’ perspective on internal medicine ward rounds: a cross-sectional study. BMC Med Educ. 2010;10:53. PubMed
14. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12):e644–e650. PubMed
15. Stone AA, Shiffman S. Capturing momentary, self-report data: A proposal for reporting guidelines. Ann Behav Med. 2002;24(3):236–243. PubMed
1. Roy B, Salanitro AH, Willett L, et al. Using cognitive mapping to identify attributes contributing to successful ward-attending rounds -- a resident and student perspective. J Gen Intern Med. 2010;25(S3):2. PubMed
2. Ben-Menachem T, Estrada C, Young MJ, et al. Balancing service and education: improving internal medicine residencies in the managed care era. Am J Med. 1996;100(2):224–229. PubMed
3. Drolet BC, Bishop KD. Unintended consequences of duty hours regulation. Acad Med. 2012;87(6):680. PubMed
4. Drolet BC, Spalluto LB, Fischer SA. Residents’ perspectives on ACGME regulation of supervision and duty hours--a national survey. N Engl J Med. 2010;363(23):e34. PubMed
5. Nasca TJ, Day SH, Amis ES, Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. PubMed
6. Shiffman S, Stone AA, Hufford MR. Ecological momentary assessment. Annu Rev Clin Psychol. 2008;4:1–32. PubMed
7. Moskowitz DS, Young SN. Ecological momentary assessment: what it is and why it is a method of the future in clinical psychopharmacology. J Psychiatry Neurosci. 2006;31(1):13–20. PubMed
8. Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169–173. PubMed
9. Goldszmidt M, Faden L, Dornan T, van Merriënboer J, Bordage G, Lingard L. Attending physician variability: a model of four supervisory styles. Acad Med. 2015;90(11):1541–1546. PubMed
10. Kennedy TJ, Lingard L, Baker GR, Kitchen L, Regehr G. Clinical oversight: conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22(8):1080–1085. PubMed
11. Irby DM. How attending physicians make instructional decisions when conducting teaching rounds. Acad Med. 1992;67(10):630–638. PubMed
12. Kennedy TJ, Regehr G, Baker GR, Lingard LA. Progressive independence in clinical training: a tradition worth defending? Acad Med. 2005;80(10):S106–S111. PubMed
13. Tariq M, Motiwala A, Ali SU, Riaz M, Awan S, Akhter J. The learners’ perspective on internal medicine ward rounds: a cross-sectional study. BMC Med Educ. 2010;10:53. PubMed
14. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12):e644–e650. PubMed
15. Stone AA, Shiffman S. Capturing momentary, self-report data: A proposal for reporting guidelines. Ann Behav Med. 2002;24(3):236–243. PubMed
© 2017 Society of Hospital Medicine
Different Strokes for Different Folks
A 35‐year‐old woman presented to her primary care physician complaining of left post‐auricular pain, swelling, and redness. She described the pain as 8 out of 10, constant, sharp, and nonradiating. She denied fever or chills. A presumptive diagnosis of cellulitis led to a prescription for oral trimethoprim‐sulfamethoxazole. Left facial swelling worsened despite 4 days of antibiotics, so she came to the emergency department.
Noninfectious causes of this woman's symptoms include trauma, or an inflammatory condition such as polychondritis. Key infectious considerations are mastoiditis or a mastoid abscess. Herpes zoster with involvement of the pinna and auditory canal may also present with pain and redness. In the absence of findings suggestive of an infection arising from the auditory canal, cellulitis is a reasonable consideration. With the growing incidence of community‐acquired methicillin‐resistant Staphylococcus aureus infections, an agent effective against this pathogen such as trimethoprim‐sulfamethoxazole may be used, usually in combination with an antibiotic that provides more reliable coverage for group A streptococcus.
Her past medical history included poorly controlled type II diabetes mellitus and asthma. She reported no previous surgical history. Her current medications were insulin, albuterol inhaler, and trimethoprim‐sulfamethoxazole, although she had a history of noncompliance with her insulin. She was married with 1 child and was unemployed. She smoked 1 pack of cigarettes daily, drank up to 6 beers daily, and denied use of illicit drugs.
Her history of diabetes increases her risk of malignant otitis externa. Both diabetes and excess alcohol consumption are risk factors for herpes zoster. Smoking has been shown to increase the risk of otitis media and carriage by S. pneumoniae, a common pathogen in ear infections.
She was ill‐appearing and in moderate respiratory distress. Her temperature was 39C, blood pressure 149/93 mmHg, pulse 95 beats per minute, respiratory rate of 26 times per minute, with an oxygen saturation of 96% while breathing ambient air. She had swelling of the left side of the face extending to the left forehead and lateral neck. Examination of the external ear and auditory canal were unremarkable. The swelling had no associated erythema, tenderness, or lymphadenopathy. She had no oropharyngeal or nasal ulcers present. Her pupils were equal, round, and reactive to light and accommodation with normal sclera. Her trachea was midline; thyroid exam was normal. The heart sounds included normal S1 and S2 without murmurs, rubs, or gallops. Her lung exam was remarkable for inspiratory stridor. The abdominal examination revealed no distention, tenderness, organomegaly, or masses. Cranial nerve testing revealed a left‐sided central seventh nerve palsy along with decreased visual acuity of the left eye. Strength, sensation, and deep tendon reflexes were normal.
While there are many causes of facial nerve palsy, distinguishing between a peripheral palsy (which causes paralysis of the entire ipsilateral side of the face) and a central palsy (which spares the musculature of the forehead) is important. The most common type of peripheral facial nerve palsy is Bell's palsy. Infections such as meningitis or tumors of the central nervous system can cause central facial nerve or other cranial nerve palsy. Important infections to consider in this case would be viral such as herpes zoster or simplex, or atypical bacteria such as Mycoplasma and Rickettsia, which may explain the neurologic but not all of the other clinical findings in this case. It is also critical to determine whether she has an isolated seventh cranial nerve palsy or if other cranial nerves are involved such as may occur with basilar meningitis, which has a myriad of infectious and noninfectious causes. The decreased visual acuity may be a result of corneal dryness and abrasions from inability to close the eye but may also represent optic nerve problems, so detailed ophthalmologic exam is essential. Her ill appearance coupled with facial and neck swelling leads me to at least consider Lemierre's syndrome with central nervous system involvement. Finally, facial swelling and the inspiratory stridor may represent angioedema, although one‐sided involvement of the face would be unusual.
The results of initial laboratory testing were as follows: sodium, 138 mmol/L; potassium, 3.4 mmol/L; chloride, 109 mmol/L; bicarbonate, 14 mmol/L; blood urea nitrogen level, 19 mg/dL; creatinine, 1.1 mg/dL; white cell count, 23,510/mm3; differential, 90% neutrophils, 1% bands, 7% lymphocytes, 2% monocytes; hemoglobin level, 12.5 g/dL; platelet count, 566,000/mm3; hemoglobin A1c, 11%; albumin, 1.6 g/dL; total protein, 6.2 g/dL; total bilirubin, 0.8 mg/dL; alkaline phosphatase, 103 U/L; alanine aminotransferase level, 14 U/L; international normalized ratio of 1.2; partial thromboplastin time, 29 seconds (normal value, 2434 seconds); erythrocyte sedimentation rate, 121 mm/hr; creatine kinase, 561 U/L (normal value 25190). Arterial blood gas measurements with the patient breathing 50% oxygen revealed a pH of 7.34, a partial pressure of carbon dioxide of 28 mmHg, and a partial pressure of oxygen of 228 mmHg.
I am concerned that this patient has sepsis, likely due to an infectious trigger. With her clinical presentation localized to the head and neck, her history of diabetes, and the accelerated sedimentation rate, malignant otitis externa would explain many of her findings. Empiric anti‐infective therapy directed toward Pseudomonas aeruginosa should be initiated, and imaging of the head and ear should be undertaken.
The patient required intubation due to increased respiratory distress and stridor. Her physicians used intravenous vancomycin, clindamycin, and piperacillin/tazobactam to treat presumed cellulitis. Her abnormal neurologic exam led to magnetic resonance (MR) imaging and MR angiography of her neck and brain, which showed evidence of multiple regions of ischemia in the left occipital and inferior parietal distributions, as well as bilateral cerebellar distributions and enhancement of the parotid gland and mastoid air cells (Figure 1). A cerebral angiogram revealed irregularity and caliber reduction in multiple cervical and intracranial arteries, associated with intraluminal thrombi within the left intracranial vertebral artery, consistent with either vasculitis or infectious angioinvasion (Figure 2).
The angioinvasive nature of the findings on imaging leads me to suspect fungal infection. The patient's history of diabetes mellitus and acidosis are risk factors for mucormycosis. Aspergillus and Fusarium may also be angioinvasive but would be much more likely in neutropenic or severely immunocompromised patients. S. aureus may cause septic emboli mimicking angioinvasion but should be readily detected in conventional blood cultures. At this point, I would empirically begin amphotericin B; tissue, however, is needed for definitive diagnosis and a surgical consult should be requested.
After reviewing her imaging studies, an investigation for vasculitis and hypercoagulable states including antinuclear antibody, anti‐deoxyribonucleic acid, anti‐Smith antibody, anti‐SSA antibody level, anti‐SSB level, antineutrophil cytoplasmic antibody, activated protein C resistance level, factor VIII level, human immunodeficiency virus antibody, homocysteine level, cardiolipin antibody testing, lupus anticoagulant, prothrombin 20210 mutation, and protein C level was done, and all tests were normal. Protein S level was slightly low at 64% (normal value 65%140%). Given the enlarged parotid gland and the enhancement of the left parotid bed on magnetic resonance imaging, she underwent a parotid biopsy that revealed sialadenitis.
Systemic vasculitides can result in tissue damage, mediated by the release of endogenous cellular contents from dying cells, known as damage‐associated molecular patterns, sufficient to cause systemic inflammatory response syndrome (SIRS). This patient presented with acute symptoms but has negative laboratory studies for autoantibodies. The parotid biopsy also did not reveal evidence of vasculitis. All these findings make the diagnosis of vasculitis much less likely.
She remained in the medical intensive care unit on mechanical ventilation, with minimal symptomatic improvement. On hospital day 10, the patient developed necrosis of the left external ear. A punch biopsy of the necrotic area of her left pinna was performed; the pathology report read: Sections of punch biopsy of skin show an unremarkable epidermis. There is dermal necrosis involving the stroma and adnexal structures. Intravascular thrombi within the deep dermis are seen. Within superficial dermis there are broad, elongated, nonseptated hyaline structures reminiscent of Mucor. Special stains (periodic acid‐Schiff stain and Grocott Gomori methenamine silver stain [GMS]) performed with appropriately reactive controls fail to highlight these structures (Figure 3). The infectious disease team reviewed the pathology slides with the pathologist. As there was inconclusive evidence for zygomycosis, ie, only a few hyaline structures which failed to stain with GMS stain, the consultants recommended no change in the patient's management.
The gross and microscopic evidence of necrosis and areas of intravascular thrombi are nonspecific but compatible with a fungal infection in a patient with risk factors for zygomycosis. The GMS stain is a very sensitive stain for fungal structures, so a negative stain in this case is surprising, but additional testing such as immunohistochemistry should be pursued to confirm or refute this diagnosis. While Rhizopus species can be contaminants, the laboratory finding of these organisms in specimens from patients with risk factors for zygomycosis should not be ignored.
On hospital day 12, the patient was noted to have increased facial swelling. A computed tomographic (CT) angiogram of the neck revealed necrosis of the anterior and posterior paraspinal muscles from the skull base to C34, marked swelling of the left parotid gland, and left inferior parieto‐occipital enhancing lesion. An incisional parotid biopsy was performed. Special stains were positive for broad‐based fungal hyphae consistent with mucormycosis (Figure 4).
Given these findings, the patient should be started on amphotericin B immediately. Medical therapy alone generally does not suffice, and aggressive surgical debridement combined with intravenous antifungal therapy results in better outcomes. The longer the duration of symptoms and the greater the progression of disease, the less favorable the prognosis.
The patient was started on amphotericin B lipid complex and micafungin. However, after 16 days of therapy, repeat imaging of the neck showed worsening necrosis of the neck muscles. At this time, she underwent extensive debridement of face and neck, and posaconazole was added. After prolonged hospitalization, she was discharged to a rehabilitation facility on posaconazole. She resided in a nursing facility for 6 months. One year after her hospitalization, she is living at home and is able to ambulate independently, but requires feeding through a percutaneous endoscopic gastrostomy (PEG) tube because she remains dysphagic.
COMMENTARY
Infections caused by the ubiquitous fungi of the class Zygomycetes typically take 1 of 5 forms: rhinocerebral, pulmonary, gastrointestinal, disseminated, and cutaneous. The presentation varies widely, ranging from plaques, skin swelling, pustules, cellulitis, blisters, nodules, ulcerations, and ecthyma gangrenosum‐like lesions to deeper infections such as necrotizing fasciitis, osteomyelitis, and disseminated infection.1 Infections typically occur in immunocompromised hosts, including transplant recipients and patients with hematologic malignancy, but also occur in patients with diabetes mellitus, intravenous drug users, and patients on deferoxamine therapy.2 Deferoxamine and other iron‐binding therapy is thought to predispose to zygomycetes infections because of improved iron uptake of the fungal species and, thus, stimulation of growth.3 Pulmonary and rhinocerebral infections are the most common clinically encountered forms, and 44% of cutaneous infections are complicated by deep extension or dissemination.4
The articles cited above describe the more typical presentations of this rare disease. However, this patient had an unusual presentation, as parotid involvement due to zygomycosis has only been described once previously.5 Her inflammatory vasculitis and ensuing strokes from involvement of the carotid artery are recognized complications of zygomycosis, and in 1 case series of 41 patients with rhinocerebral mucormycosis, carotid involvement was seen in 31% of patients.6 After the punch biopsy of the patient's pinna showing nonseptated hyphae reminiscent of Mucor, why did her physicians delay administering amphotericin?
There are 2 likely possibilities: anchoring bias or error in medical decision‐making due to inaccurate probability estimates. Anchoring bias describes a heuristic where the initial diagnosis or gestalt biases the physician's process for assigning a final diagnosis.7, 8 This bias creates cognitive errors by limiting creativity in diagnosis. In this case, the infectious disease team carefully weighed the information obtained from the first biopsy. Given their low pretest estimate of this virtually unreported presentation of a rare disease, they decided to evaluate further without beginning antifungal therapy. Of note, there were few hyaline structures, and those structures lacked uptake of GMS. Since they considered the diagnosis yet rejected the diagnosis due to insufficient evidence, it is unlikely that anchoring bias played a role.
Was there an error in medical decision‐making? The physicians in this case faced a very common medical dilemma: whether or not to start a toxic medication empirically or wait for diagnostic confirmation prior to treatment.9 To solve this dilemma, one can apply decision analysis. Moskowitz et al described 5 phases of medical decision analysis by which a probabilistic right answer to clinical scenarios can be deduced mathematically.10 To solve this problem, probabilities must be assigned to the risk of giving a drug to a patient without the disease versus the risk of not giving a drug to a patient with the disease. For example, amphotericin deoxycholate causes acute renal failure in 30% to 47% of patients. Newer formulations of amphotericin, such as liposomal amphotericin and lipid complex, result in lower rates of nephrotoxicity (27% vs 47%). The risk of not giving amphotericin to a patient with zygomycosis is death. Even in patients treated with amphotericin, the mortality rate has been shown to be 66%, and up to 100% in those with strokes related to zygomycosis.2, 6, 11 Simply looking at these probabilities, decision analysis would favor empiric treatment.
The physicians caring for this patient did not have the luxury of retrospective speculation. After looking at all of the data, the equivocal skin biopsy and rare clinical presentation, the question to ask would change: What is the risk of giving amphotericin empirically to someone who, based on available information, has a very low probability of having zygomycosis? When phrased in this manner, there is a 47% chance of nephrotoxicity with amphotericin versus the very small probability that you have diagnosed a case of zygomycosis that has only been described once in the literature. Mathematically andmore importantlyclinically, this question becomes more difficult to answer. However, no value can be placed on the possibility of death in suspected zygomycosis, and the risk of short‐term amphotericin use is much less than that of a course of treatment. As such, empiric therapy should always be given.
Physicians are not mathematicians, and dynamic clinical scenarios are not so easily made into static math problems. Disease presentations evolve over time towards a diagnosable clinical pattern, as was the case with this patient. Two days after the aforementioned biopsy, she worsened and in less time than it would have taken to isolate zygomycosis from the first biopsy, a second biopsy revealed the typical nonseptated hyphae demarcated with the GMS stain. Even appropriate diagnostic testing, thoughtful interpretation, and avoidance of certain cognitive errors can result in incorrect diagnoses and delayed treatment. It is monitoring the progression of disease and collecting additional data that allows physicians to mold a diagnosis and create a treatment plan.
The primary treatment of zygomycosis should include amphotericin. However, there are limited data to support combination therapy with an echinocandin in severe cases, as in this patient.12 Posaconazole is not recommended for monotherapy as an initial therapy, but there is data for its use as salvage therapy in zygomycosis.13 This case highlights the difficulties that physicians face in the diagnosis and treatment of rare diseases. Cerebral infarction in a hematologic malignancy, uncontrolled diabetes, or iron chelation therapy could be the initial presentation of rhinocerebral zygomycosis. There truly are different strokes for different folks. Recognizing this and similar presentations may lead to a more rapid diagnosis and treatment of zygomycosis.
TEACHING POINTS
-
Zygomycosis has a wide range of clinical presentations ranging from skin lesions to deep tissue infections. As it is an angioinvasive organism, it can also present as cerebral infarcts and brain abscesses.
-
Zygomycosis infections should be suspected in patients with uncontrolled diabetes, hematologic or oncologic malignancies, and patients on iron chelation therapy with a potentially compatible clinical picture.
-
If zygomycosis infection is suspected, rapid histologic diagnosis should be attempted. However, as histologic diagnosis can take time, empiric therapy with amphotericin should always be administered.
-
Amphotericin remains the primary medical therapy for this disease; however, there is limited emerging evidence to suggest that echinocandins can be used in combination with amphotericin for improved treatment of severe rhinocerebral zygomyocosis. Posaconazole has a role as salvage therapy in zygomycosis, but should not be used as the sole primary treatment.
The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant.
This icon represents the patient's case. Each paragraph that follows represents the discussant's thoughts.
Acknowledgements
The authors are indebted to Dr Glenn Roberson at the Department of Radiology, University of Alabama at Birmingham, for providing the radiographic images; to Dr Aleodor Andea at the Department of Pathology, University of Alabama at Birmingham, for providing the pathology images; and to Dr. Crysten Brinkley at the Department of Neurology at the University of Alabama at Birmingham for her assistance with this case presentation.
Disclosure: Nothing to report.
- ,,,.Mucormycosis: emerging prominence of cutaneous infections.Clin Infect Dis.1994;19:67–76.
- ,,,.Zygomycosis in the 1990s in a tertiary‐care cancer center.Clin Infect Dis.2000;30:851–856.
- ,,, et al.Mucormycosis during deferoxamine therapy is a siderophore‐mediated infection. In vitro and in vivo animal studies.J Clin Invest.1993;91:1979–1986.
- ,,, et al.Epidemiology and outcome of zygomycosis: a review of 929 reported cases.Clin Infect Dis.2005;41:634–653.
- ,,,,,.Cutaneous mucormycosis of the head and neck with parotid gland involvement: first report of a case.Ear Nose Throat J.2004;83:282–286.
- ,,,,,.A successful combined endovascular and surgical treatment of a cranial base mucormycosis with an associated internal carotid artery pseudoaneurysm.Neurosurgery.2009;65:733–740.
- ,.Judgment under uncertainty: heuristics and biases.Science.1974;185:1124–1131.
- ,,,,.Clinical problem‐solving. Anchors away.N Engl J Med.2007;356:504–509.
- ,,,.Clinical problem‐solving. Empirically incorrect.N Engl J Med.2006;354:509–514.
- ,,.Dealing with uncertainty, risks, and tradeoffs in clinical decisions. A cognitive science approach.Ann Intern Med.1988;108:435–449.
- ,,.Fatal strokes in patients with rhino‐orbito‐cerebral mucormycosis and associated vasculopathy.Scand J Infect Dis.2004;36:643–648.
- ,,, et al.Combination polyene‐caspofungin treatment of rhino‐orbital‐cerebral mucormycosis.Clin Infect Dis.2008;47:364–371.
- ,,,,.Posaconazole is effective as salvage therapy in zygomycosis: a retrospective summary of 91 cases.Clin Infect Dis.2006;42:e61–e65.
A 35‐year‐old woman presented to her primary care physician complaining of left post‐auricular pain, swelling, and redness. She described the pain as 8 out of 10, constant, sharp, and nonradiating. She denied fever or chills. A presumptive diagnosis of cellulitis led to a prescription for oral trimethoprim‐sulfamethoxazole. Left facial swelling worsened despite 4 days of antibiotics, so she came to the emergency department.
Noninfectious causes of this woman's symptoms include trauma, or an inflammatory condition such as polychondritis. Key infectious considerations are mastoiditis or a mastoid abscess. Herpes zoster with involvement of the pinna and auditory canal may also present with pain and redness. In the absence of findings suggestive of an infection arising from the auditory canal, cellulitis is a reasonable consideration. With the growing incidence of community‐acquired methicillin‐resistant Staphylococcus aureus infections, an agent effective against this pathogen such as trimethoprim‐sulfamethoxazole may be used, usually in combination with an antibiotic that provides more reliable coverage for group A streptococcus.
Her past medical history included poorly controlled type II diabetes mellitus and asthma. She reported no previous surgical history. Her current medications were insulin, albuterol inhaler, and trimethoprim‐sulfamethoxazole, although she had a history of noncompliance with her insulin. She was married with 1 child and was unemployed. She smoked 1 pack of cigarettes daily, drank up to 6 beers daily, and denied use of illicit drugs.
Her history of diabetes increases her risk of malignant otitis externa. Both diabetes and excess alcohol consumption are risk factors for herpes zoster. Smoking has been shown to increase the risk of otitis media and carriage by S. pneumoniae, a common pathogen in ear infections.
She was ill‐appearing and in moderate respiratory distress. Her temperature was 39C, blood pressure 149/93 mmHg, pulse 95 beats per minute, respiratory rate of 26 times per minute, with an oxygen saturation of 96% while breathing ambient air. She had swelling of the left side of the face extending to the left forehead and lateral neck. Examination of the external ear and auditory canal were unremarkable. The swelling had no associated erythema, tenderness, or lymphadenopathy. She had no oropharyngeal or nasal ulcers present. Her pupils were equal, round, and reactive to light and accommodation with normal sclera. Her trachea was midline; thyroid exam was normal. The heart sounds included normal S1 and S2 without murmurs, rubs, or gallops. Her lung exam was remarkable for inspiratory stridor. The abdominal examination revealed no distention, tenderness, organomegaly, or masses. Cranial nerve testing revealed a left‐sided central seventh nerve palsy along with decreased visual acuity of the left eye. Strength, sensation, and deep tendon reflexes were normal.
While there are many causes of facial nerve palsy, distinguishing between a peripheral palsy (which causes paralysis of the entire ipsilateral side of the face) and a central palsy (which spares the musculature of the forehead) is important. The most common type of peripheral facial nerve palsy is Bell's palsy. Infections such as meningitis or tumors of the central nervous system can cause central facial nerve or other cranial nerve palsy. Important infections to consider in this case would be viral such as herpes zoster or simplex, or atypical bacteria such as Mycoplasma and Rickettsia, which may explain the neurologic but not all of the other clinical findings in this case. It is also critical to determine whether she has an isolated seventh cranial nerve palsy or if other cranial nerves are involved such as may occur with basilar meningitis, which has a myriad of infectious and noninfectious causes. The decreased visual acuity may be a result of corneal dryness and abrasions from inability to close the eye but may also represent optic nerve problems, so detailed ophthalmologic exam is essential. Her ill appearance coupled with facial and neck swelling leads me to at least consider Lemierre's syndrome with central nervous system involvement. Finally, facial swelling and the inspiratory stridor may represent angioedema, although one‐sided involvement of the face would be unusual.
The results of initial laboratory testing were as follows: sodium, 138 mmol/L; potassium, 3.4 mmol/L; chloride, 109 mmol/L; bicarbonate, 14 mmol/L; blood urea nitrogen level, 19 mg/dL; creatinine, 1.1 mg/dL; white cell count, 23,510/mm3; differential, 90% neutrophils, 1% bands, 7% lymphocytes, 2% monocytes; hemoglobin level, 12.5 g/dL; platelet count, 566,000/mm3; hemoglobin A1c, 11%; albumin, 1.6 g/dL; total protein, 6.2 g/dL; total bilirubin, 0.8 mg/dL; alkaline phosphatase, 103 U/L; alanine aminotransferase level, 14 U/L; international normalized ratio of 1.2; partial thromboplastin time, 29 seconds (normal value, 2434 seconds); erythrocyte sedimentation rate, 121 mm/hr; creatine kinase, 561 U/L (normal value 25190). Arterial blood gas measurements with the patient breathing 50% oxygen revealed a pH of 7.34, a partial pressure of carbon dioxide of 28 mmHg, and a partial pressure of oxygen of 228 mmHg.
I am concerned that this patient has sepsis, likely due to an infectious trigger. With her clinical presentation localized to the head and neck, her history of diabetes, and the accelerated sedimentation rate, malignant otitis externa would explain many of her findings. Empiric anti‐infective therapy directed toward Pseudomonas aeruginosa should be initiated, and imaging of the head and ear should be undertaken.
The patient required intubation due to increased respiratory distress and stridor. Her physicians used intravenous vancomycin, clindamycin, and piperacillin/tazobactam to treat presumed cellulitis. Her abnormal neurologic exam led to magnetic resonance (MR) imaging and MR angiography of her neck and brain, which showed evidence of multiple regions of ischemia in the left occipital and inferior parietal distributions, as well as bilateral cerebellar distributions and enhancement of the parotid gland and mastoid air cells (Figure 1). A cerebral angiogram revealed irregularity and caliber reduction in multiple cervical and intracranial arteries, associated with intraluminal thrombi within the left intracranial vertebral artery, consistent with either vasculitis or infectious angioinvasion (Figure 2).
The angioinvasive nature of the findings on imaging leads me to suspect fungal infection. The patient's history of diabetes mellitus and acidosis are risk factors for mucormycosis. Aspergillus and Fusarium may also be angioinvasive but would be much more likely in neutropenic or severely immunocompromised patients. S. aureus may cause septic emboli mimicking angioinvasion but should be readily detected in conventional blood cultures. At this point, I would empirically begin amphotericin B; tissue, however, is needed for definitive diagnosis and a surgical consult should be requested.
After reviewing her imaging studies, an investigation for vasculitis and hypercoagulable states including antinuclear antibody, anti‐deoxyribonucleic acid, anti‐Smith antibody, anti‐SSA antibody level, anti‐SSB level, antineutrophil cytoplasmic antibody, activated protein C resistance level, factor VIII level, human immunodeficiency virus antibody, homocysteine level, cardiolipin antibody testing, lupus anticoagulant, prothrombin 20210 mutation, and protein C level was done, and all tests were normal. Protein S level was slightly low at 64% (normal value 65%140%). Given the enlarged parotid gland and the enhancement of the left parotid bed on magnetic resonance imaging, she underwent a parotid biopsy that revealed sialadenitis.
Systemic vasculitides can result in tissue damage, mediated by the release of endogenous cellular contents from dying cells, known as damage‐associated molecular patterns, sufficient to cause systemic inflammatory response syndrome (SIRS). This patient presented with acute symptoms but has negative laboratory studies for autoantibodies. The parotid biopsy also did not reveal evidence of vasculitis. All these findings make the diagnosis of vasculitis much less likely.
She remained in the medical intensive care unit on mechanical ventilation, with minimal symptomatic improvement. On hospital day 10, the patient developed necrosis of the left external ear. A punch biopsy of the necrotic area of her left pinna was performed; the pathology report read: Sections of punch biopsy of skin show an unremarkable epidermis. There is dermal necrosis involving the stroma and adnexal structures. Intravascular thrombi within the deep dermis are seen. Within superficial dermis there are broad, elongated, nonseptated hyaline structures reminiscent of Mucor. Special stains (periodic acid‐Schiff stain and Grocott Gomori methenamine silver stain [GMS]) performed with appropriately reactive controls fail to highlight these structures (Figure 3). The infectious disease team reviewed the pathology slides with the pathologist. As there was inconclusive evidence for zygomycosis, ie, only a few hyaline structures which failed to stain with GMS stain, the consultants recommended no change in the patient's management.
The gross and microscopic evidence of necrosis and areas of intravascular thrombi are nonspecific but compatible with a fungal infection in a patient with risk factors for zygomycosis. The GMS stain is a very sensitive stain for fungal structures, so a negative stain in this case is surprising, but additional testing such as immunohistochemistry should be pursued to confirm or refute this diagnosis. While Rhizopus species can be contaminants, the laboratory finding of these organisms in specimens from patients with risk factors for zygomycosis should not be ignored.
On hospital day 12, the patient was noted to have increased facial swelling. A computed tomographic (CT) angiogram of the neck revealed necrosis of the anterior and posterior paraspinal muscles from the skull base to C34, marked swelling of the left parotid gland, and left inferior parieto‐occipital enhancing lesion. An incisional parotid biopsy was performed. Special stains were positive for broad‐based fungal hyphae consistent with mucormycosis (Figure 4).
Given these findings, the patient should be started on amphotericin B immediately. Medical therapy alone generally does not suffice, and aggressive surgical debridement combined with intravenous antifungal therapy results in better outcomes. The longer the duration of symptoms and the greater the progression of disease, the less favorable the prognosis.
The patient was started on amphotericin B lipid complex and micafungin. However, after 16 days of therapy, repeat imaging of the neck showed worsening necrosis of the neck muscles. At this time, she underwent extensive debridement of face and neck, and posaconazole was added. After prolonged hospitalization, she was discharged to a rehabilitation facility on posaconazole. She resided in a nursing facility for 6 months. One year after her hospitalization, she is living at home and is able to ambulate independently, but requires feeding through a percutaneous endoscopic gastrostomy (PEG) tube because she remains dysphagic.
COMMENTARY
Infections caused by the ubiquitous fungi of the class Zygomycetes typically take 1 of 5 forms: rhinocerebral, pulmonary, gastrointestinal, disseminated, and cutaneous. The presentation varies widely, ranging from plaques, skin swelling, pustules, cellulitis, blisters, nodules, ulcerations, and ecthyma gangrenosum‐like lesions to deeper infections such as necrotizing fasciitis, osteomyelitis, and disseminated infection.1 Infections typically occur in immunocompromised hosts, including transplant recipients and patients with hematologic malignancy, but also occur in patients with diabetes mellitus, intravenous drug users, and patients on deferoxamine therapy.2 Deferoxamine and other iron‐binding therapy is thought to predispose to zygomycetes infections because of improved iron uptake of the fungal species and, thus, stimulation of growth.3 Pulmonary and rhinocerebral infections are the most common clinically encountered forms, and 44% of cutaneous infections are complicated by deep extension or dissemination.4
The articles cited above describe the more typical presentations of this rare disease. However, this patient had an unusual presentation, as parotid involvement due to zygomycosis has only been described once previously.5 Her inflammatory vasculitis and ensuing strokes from involvement of the carotid artery are recognized complications of zygomycosis, and in 1 case series of 41 patients with rhinocerebral mucormycosis, carotid involvement was seen in 31% of patients.6 After the punch biopsy of the patient's pinna showing nonseptated hyphae reminiscent of Mucor, why did her physicians delay administering amphotericin?
There are 2 likely possibilities: anchoring bias or error in medical decision‐making due to inaccurate probability estimates. Anchoring bias describes a heuristic where the initial diagnosis or gestalt biases the physician's process for assigning a final diagnosis.7, 8 This bias creates cognitive errors by limiting creativity in diagnosis. In this case, the infectious disease team carefully weighed the information obtained from the first biopsy. Given their low pretest estimate of this virtually unreported presentation of a rare disease, they decided to evaluate further without beginning antifungal therapy. Of note, there were few hyaline structures, and those structures lacked uptake of GMS. Since they considered the diagnosis yet rejected the diagnosis due to insufficient evidence, it is unlikely that anchoring bias played a role.
Was there an error in medical decision‐making? The physicians in this case faced a very common medical dilemma: whether or not to start a toxic medication empirically or wait for diagnostic confirmation prior to treatment.9 To solve this dilemma, one can apply decision analysis. Moskowitz et al described 5 phases of medical decision analysis by which a probabilistic right answer to clinical scenarios can be deduced mathematically.10 To solve this problem, probabilities must be assigned to the risk of giving a drug to a patient without the disease versus the risk of not giving a drug to a patient with the disease. For example, amphotericin deoxycholate causes acute renal failure in 30% to 47% of patients. Newer formulations of amphotericin, such as liposomal amphotericin and lipid complex, result in lower rates of nephrotoxicity (27% vs 47%). The risk of not giving amphotericin to a patient with zygomycosis is death. Even in patients treated with amphotericin, the mortality rate has been shown to be 66%, and up to 100% in those with strokes related to zygomycosis.2, 6, 11 Simply looking at these probabilities, decision analysis would favor empiric treatment.
The physicians caring for this patient did not have the luxury of retrospective speculation. After looking at all of the data, the equivocal skin biopsy and rare clinical presentation, the question to ask would change: What is the risk of giving amphotericin empirically to someone who, based on available information, has a very low probability of having zygomycosis? When phrased in this manner, there is a 47% chance of nephrotoxicity with amphotericin versus the very small probability that you have diagnosed a case of zygomycosis that has only been described once in the literature. Mathematically andmore importantlyclinically, this question becomes more difficult to answer. However, no value can be placed on the possibility of death in suspected zygomycosis, and the risk of short‐term amphotericin use is much less than that of a course of treatment. As such, empiric therapy should always be given.
Physicians are not mathematicians, and dynamic clinical scenarios are not so easily made into static math problems. Disease presentations evolve over time towards a diagnosable clinical pattern, as was the case with this patient. Two days after the aforementioned biopsy, she worsened and in less time than it would have taken to isolate zygomycosis from the first biopsy, a second biopsy revealed the typical nonseptated hyphae demarcated with the GMS stain. Even appropriate diagnostic testing, thoughtful interpretation, and avoidance of certain cognitive errors can result in incorrect diagnoses and delayed treatment. It is monitoring the progression of disease and collecting additional data that allows physicians to mold a diagnosis and create a treatment plan.
The primary treatment of zygomycosis should include amphotericin. However, there are limited data to support combination therapy with an echinocandin in severe cases, as in this patient.12 Posaconazole is not recommended for monotherapy as an initial therapy, but there is data for its use as salvage therapy in zygomycosis.13 This case highlights the difficulties that physicians face in the diagnosis and treatment of rare diseases. Cerebral infarction in a hematologic malignancy, uncontrolled diabetes, or iron chelation therapy could be the initial presentation of rhinocerebral zygomycosis. There truly are different strokes for different folks. Recognizing this and similar presentations may lead to a more rapid diagnosis and treatment of zygomycosis.
TEACHING POINTS
-
Zygomycosis has a wide range of clinical presentations ranging from skin lesions to deep tissue infections. As it is an angioinvasive organism, it can also present as cerebral infarcts and brain abscesses.
-
Zygomycosis infections should be suspected in patients with uncontrolled diabetes, hematologic or oncologic malignancies, and patients on iron chelation therapy with a potentially compatible clinical picture.
-
If zygomycosis infection is suspected, rapid histologic diagnosis should be attempted. However, as histologic diagnosis can take time, empiric therapy with amphotericin should always be administered.
-
Amphotericin remains the primary medical therapy for this disease; however, there is limited emerging evidence to suggest that echinocandins can be used in combination with amphotericin for improved treatment of severe rhinocerebral zygomyocosis. Posaconazole has a role as salvage therapy in zygomycosis, but should not be used as the sole primary treatment.
The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant.
This icon represents the patient's case. Each paragraph that follows represents the discussant's thoughts.
Acknowledgements
The authors are indebted to Dr Glenn Roberson at the Department of Radiology, University of Alabama at Birmingham, for providing the radiographic images; to Dr Aleodor Andea at the Department of Pathology, University of Alabama at Birmingham, for providing the pathology images; and to Dr. Crysten Brinkley at the Department of Neurology at the University of Alabama at Birmingham for her assistance with this case presentation.
Disclosure: Nothing to report.
A 35‐year‐old woman presented to her primary care physician complaining of left post‐auricular pain, swelling, and redness. She described the pain as 8 out of 10, constant, sharp, and nonradiating. She denied fever or chills. A presumptive diagnosis of cellulitis led to a prescription for oral trimethoprim‐sulfamethoxazole. Left facial swelling worsened despite 4 days of antibiotics, so she came to the emergency department.
Noninfectious causes of this woman's symptoms include trauma, or an inflammatory condition such as polychondritis. Key infectious considerations are mastoiditis or a mastoid abscess. Herpes zoster with involvement of the pinna and auditory canal may also present with pain and redness. In the absence of findings suggestive of an infection arising from the auditory canal, cellulitis is a reasonable consideration. With the growing incidence of community‐acquired methicillin‐resistant Staphylococcus aureus infections, an agent effective against this pathogen such as trimethoprim‐sulfamethoxazole may be used, usually in combination with an antibiotic that provides more reliable coverage for group A streptococcus.
Her past medical history included poorly controlled type II diabetes mellitus and asthma. She reported no previous surgical history. Her current medications were insulin, albuterol inhaler, and trimethoprim‐sulfamethoxazole, although she had a history of noncompliance with her insulin. She was married with 1 child and was unemployed. She smoked 1 pack of cigarettes daily, drank up to 6 beers daily, and denied use of illicit drugs.
Her history of diabetes increases her risk of malignant otitis externa. Both diabetes and excess alcohol consumption are risk factors for herpes zoster. Smoking has been shown to increase the risk of otitis media and carriage by S. pneumoniae, a common pathogen in ear infections.
She was ill‐appearing and in moderate respiratory distress. Her temperature was 39C, blood pressure 149/93 mmHg, pulse 95 beats per minute, respiratory rate of 26 times per minute, with an oxygen saturation of 96% while breathing ambient air. She had swelling of the left side of the face extending to the left forehead and lateral neck. Examination of the external ear and auditory canal were unremarkable. The swelling had no associated erythema, tenderness, or lymphadenopathy. She had no oropharyngeal or nasal ulcers present. Her pupils were equal, round, and reactive to light and accommodation with normal sclera. Her trachea was midline; thyroid exam was normal. The heart sounds included normal S1 and S2 without murmurs, rubs, or gallops. Her lung exam was remarkable for inspiratory stridor. The abdominal examination revealed no distention, tenderness, organomegaly, or masses. Cranial nerve testing revealed a left‐sided central seventh nerve palsy along with decreased visual acuity of the left eye. Strength, sensation, and deep tendon reflexes were normal.
While there are many causes of facial nerve palsy, distinguishing between a peripheral palsy (which causes paralysis of the entire ipsilateral side of the face) and a central palsy (which spares the musculature of the forehead) is important. The most common type of peripheral facial nerve palsy is Bell's palsy. Infections such as meningitis or tumors of the central nervous system can cause central facial nerve or other cranial nerve palsy. Important infections to consider in this case would be viral such as herpes zoster or simplex, or atypical bacteria such as Mycoplasma and Rickettsia, which may explain the neurologic but not all of the other clinical findings in this case. It is also critical to determine whether she has an isolated seventh cranial nerve palsy or if other cranial nerves are involved such as may occur with basilar meningitis, which has a myriad of infectious and noninfectious causes. The decreased visual acuity may be a result of corneal dryness and abrasions from inability to close the eye but may also represent optic nerve problems, so detailed ophthalmologic exam is essential. Her ill appearance coupled with facial and neck swelling leads me to at least consider Lemierre's syndrome with central nervous system involvement. Finally, facial swelling and the inspiratory stridor may represent angioedema, although one‐sided involvement of the face would be unusual.
The results of initial laboratory testing were as follows: sodium, 138 mmol/L; potassium, 3.4 mmol/L; chloride, 109 mmol/L; bicarbonate, 14 mmol/L; blood urea nitrogen level, 19 mg/dL; creatinine, 1.1 mg/dL; white cell count, 23,510/mm3; differential, 90% neutrophils, 1% bands, 7% lymphocytes, 2% monocytes; hemoglobin level, 12.5 g/dL; platelet count, 566,000/mm3; hemoglobin A1c, 11%; albumin, 1.6 g/dL; total protein, 6.2 g/dL; total bilirubin, 0.8 mg/dL; alkaline phosphatase, 103 U/L; alanine aminotransferase level, 14 U/L; international normalized ratio of 1.2; partial thromboplastin time, 29 seconds (normal value, 2434 seconds); erythrocyte sedimentation rate, 121 mm/hr; creatine kinase, 561 U/L (normal value 25190). Arterial blood gas measurements with the patient breathing 50% oxygen revealed a pH of 7.34, a partial pressure of carbon dioxide of 28 mmHg, and a partial pressure of oxygen of 228 mmHg.
I am concerned that this patient has sepsis, likely due to an infectious trigger. With her clinical presentation localized to the head and neck, her history of diabetes, and the accelerated sedimentation rate, malignant otitis externa would explain many of her findings. Empiric anti‐infective therapy directed toward Pseudomonas aeruginosa should be initiated, and imaging of the head and ear should be undertaken.
The patient required intubation due to increased respiratory distress and stridor. Her physicians used intravenous vancomycin, clindamycin, and piperacillin/tazobactam to treat presumed cellulitis. Her abnormal neurologic exam led to magnetic resonance (MR) imaging and MR angiography of her neck and brain, which showed evidence of multiple regions of ischemia in the left occipital and inferior parietal distributions, as well as bilateral cerebellar distributions and enhancement of the parotid gland and mastoid air cells (Figure 1). A cerebral angiogram revealed irregularity and caliber reduction in multiple cervical and intracranial arteries, associated with intraluminal thrombi within the left intracranial vertebral artery, consistent with either vasculitis or infectious angioinvasion (Figure 2).
The angioinvasive nature of the findings on imaging leads me to suspect fungal infection. The patient's history of diabetes mellitus and acidosis are risk factors for mucormycosis. Aspergillus and Fusarium may also be angioinvasive but would be much more likely in neutropenic or severely immunocompromised patients. S. aureus may cause septic emboli mimicking angioinvasion but should be readily detected in conventional blood cultures. At this point, I would empirically begin amphotericin B; tissue, however, is needed for definitive diagnosis and a surgical consult should be requested.
After reviewing her imaging studies, an investigation for vasculitis and hypercoagulable states including antinuclear antibody, anti‐deoxyribonucleic acid, anti‐Smith antibody, anti‐SSA antibody level, anti‐SSB level, antineutrophil cytoplasmic antibody, activated protein C resistance level, factor VIII level, human immunodeficiency virus antibody, homocysteine level, cardiolipin antibody testing, lupus anticoagulant, prothrombin 20210 mutation, and protein C level was done, and all tests were normal. Protein S level was slightly low at 64% (normal value 65%140%). Given the enlarged parotid gland and the enhancement of the left parotid bed on magnetic resonance imaging, she underwent a parotid biopsy that revealed sialadenitis.
Systemic vasculitides can result in tissue damage, mediated by the release of endogenous cellular contents from dying cells, known as damage‐associated molecular patterns, sufficient to cause systemic inflammatory response syndrome (SIRS). This patient presented with acute symptoms but has negative laboratory studies for autoantibodies. The parotid biopsy also did not reveal evidence of vasculitis. All these findings make the diagnosis of vasculitis much less likely.
She remained in the medical intensive care unit on mechanical ventilation, with minimal symptomatic improvement. On hospital day 10, the patient developed necrosis of the left external ear. A punch biopsy of the necrotic area of her left pinna was performed; the pathology report read: Sections of punch biopsy of skin show an unremarkable epidermis. There is dermal necrosis involving the stroma and adnexal structures. Intravascular thrombi within the deep dermis are seen. Within superficial dermis there are broad, elongated, nonseptated hyaline structures reminiscent of Mucor. Special stains (periodic acid‐Schiff stain and Grocott Gomori methenamine silver stain [GMS]) performed with appropriately reactive controls fail to highlight these structures (Figure 3). The infectious disease team reviewed the pathology slides with the pathologist. As there was inconclusive evidence for zygomycosis, ie, only a few hyaline structures which failed to stain with GMS stain, the consultants recommended no change in the patient's management.
The gross and microscopic evidence of necrosis and areas of intravascular thrombi are nonspecific but compatible with a fungal infection in a patient with risk factors for zygomycosis. The GMS stain is a very sensitive stain for fungal structures, so a negative stain in this case is surprising, but additional testing such as immunohistochemistry should be pursued to confirm or refute this diagnosis. While Rhizopus species can be contaminants, the laboratory finding of these organisms in specimens from patients with risk factors for zygomycosis should not be ignored.
On hospital day 12, the patient was noted to have increased facial swelling. A computed tomographic (CT) angiogram of the neck revealed necrosis of the anterior and posterior paraspinal muscles from the skull base to C34, marked swelling of the left parotid gland, and left inferior parieto‐occipital enhancing lesion. An incisional parotid biopsy was performed. Special stains were positive for broad‐based fungal hyphae consistent with mucormycosis (Figure 4).
Given these findings, the patient should be started on amphotericin B immediately. Medical therapy alone generally does not suffice, and aggressive surgical debridement combined with intravenous antifungal therapy results in better outcomes. The longer the duration of symptoms and the greater the progression of disease, the less favorable the prognosis.
The patient was started on amphotericin B lipid complex and micafungin. However, after 16 days of therapy, repeat imaging of the neck showed worsening necrosis of the neck muscles. At this time, she underwent extensive debridement of face and neck, and posaconazole was added. After prolonged hospitalization, she was discharged to a rehabilitation facility on posaconazole. She resided in a nursing facility for 6 months. One year after her hospitalization, she is living at home and is able to ambulate independently, but requires feeding through a percutaneous endoscopic gastrostomy (PEG) tube because she remains dysphagic.
COMMENTARY
Infections caused by the ubiquitous fungi of the class Zygomycetes typically take 1 of 5 forms: rhinocerebral, pulmonary, gastrointestinal, disseminated, and cutaneous. The presentation varies widely, ranging from plaques, skin swelling, pustules, cellulitis, blisters, nodules, ulcerations, and ecthyma gangrenosum‐like lesions to deeper infections such as necrotizing fasciitis, osteomyelitis, and disseminated infection.1 Infections typically occur in immunocompromised hosts, including transplant recipients and patients with hematologic malignancy, but also occur in patients with diabetes mellitus, intravenous drug users, and patients on deferoxamine therapy.2 Deferoxamine and other iron‐binding therapy is thought to predispose to zygomycetes infections because of improved iron uptake of the fungal species and, thus, stimulation of growth.3 Pulmonary and rhinocerebral infections are the most common clinically encountered forms, and 44% of cutaneous infections are complicated by deep extension or dissemination.4
The articles cited above describe the more typical presentations of this rare disease. However, this patient had an unusual presentation, as parotid involvement due to zygomycosis has only been described once previously.5 Her inflammatory vasculitis and ensuing strokes from involvement of the carotid artery are recognized complications of zygomycosis, and in 1 case series of 41 patients with rhinocerebral mucormycosis, carotid involvement was seen in 31% of patients.6 After the punch biopsy of the patient's pinna showing nonseptated hyphae reminiscent of Mucor, why did her physicians delay administering amphotericin?
There are 2 likely possibilities: anchoring bias or error in medical decision‐making due to inaccurate probability estimates. Anchoring bias describes a heuristic where the initial diagnosis or gestalt biases the physician's process for assigning a final diagnosis.7, 8 This bias creates cognitive errors by limiting creativity in diagnosis. In this case, the infectious disease team carefully weighed the information obtained from the first biopsy. Given their low pretest estimate of this virtually unreported presentation of a rare disease, they decided to evaluate further without beginning antifungal therapy. Of note, there were few hyaline structures, and those structures lacked uptake of GMS. Since they considered the diagnosis yet rejected the diagnosis due to insufficient evidence, it is unlikely that anchoring bias played a role.
Was there an error in medical decision‐making? The physicians in this case faced a very common medical dilemma: whether or not to start a toxic medication empirically or wait for diagnostic confirmation prior to treatment.9 To solve this dilemma, one can apply decision analysis. Moskowitz et al described 5 phases of medical decision analysis by which a probabilistic right answer to clinical scenarios can be deduced mathematically.10 To solve this problem, probabilities must be assigned to the risk of giving a drug to a patient without the disease versus the risk of not giving a drug to a patient with the disease. For example, amphotericin deoxycholate causes acute renal failure in 30% to 47% of patients. Newer formulations of amphotericin, such as liposomal amphotericin and lipid complex, result in lower rates of nephrotoxicity (27% vs 47%). The risk of not giving amphotericin to a patient with zygomycosis is death. Even in patients treated with amphotericin, the mortality rate has been shown to be 66%, and up to 100% in those with strokes related to zygomycosis.2, 6, 11 Simply looking at these probabilities, decision analysis would favor empiric treatment.
The physicians caring for this patient did not have the luxury of retrospective speculation. After looking at all of the data, the equivocal skin biopsy and rare clinical presentation, the question to ask would change: What is the risk of giving amphotericin empirically to someone who, based on available information, has a very low probability of having zygomycosis? When phrased in this manner, there is a 47% chance of nephrotoxicity with amphotericin versus the very small probability that you have diagnosed a case of zygomycosis that has only been described once in the literature. Mathematically andmore importantlyclinically, this question becomes more difficult to answer. However, no value can be placed on the possibility of death in suspected zygomycosis, and the risk of short‐term amphotericin use is much less than that of a course of treatment. As such, empiric therapy should always be given.
Physicians are not mathematicians, and dynamic clinical scenarios are not so easily made into static math problems. Disease presentations evolve over time towards a diagnosable clinical pattern, as was the case with this patient. Two days after the aforementioned biopsy, she worsened and in less time than it would have taken to isolate zygomycosis from the first biopsy, a second biopsy revealed the typical nonseptated hyphae demarcated with the GMS stain. Even appropriate diagnostic testing, thoughtful interpretation, and avoidance of certain cognitive errors can result in incorrect diagnoses and delayed treatment. It is monitoring the progression of disease and collecting additional data that allows physicians to mold a diagnosis and create a treatment plan.
The primary treatment of zygomycosis should include amphotericin. However, there are limited data to support combination therapy with an echinocandin in severe cases, as in this patient.12 Posaconazole is not recommended for monotherapy as an initial therapy, but there is data for its use as salvage therapy in zygomycosis.13 This case highlights the difficulties that physicians face in the diagnosis and treatment of rare diseases. Cerebral infarction in a hematologic malignancy, uncontrolled diabetes, or iron chelation therapy could be the initial presentation of rhinocerebral zygomycosis. There truly are different strokes for different folks. Recognizing this and similar presentations may lead to a more rapid diagnosis and treatment of zygomycosis.
TEACHING POINTS
-
Zygomycosis has a wide range of clinical presentations ranging from skin lesions to deep tissue infections. As it is an angioinvasive organism, it can also present as cerebral infarcts and brain abscesses.
-
Zygomycosis infections should be suspected in patients with uncontrolled diabetes, hematologic or oncologic malignancies, and patients on iron chelation therapy with a potentially compatible clinical picture.
-
If zygomycosis infection is suspected, rapid histologic diagnosis should be attempted. However, as histologic diagnosis can take time, empiric therapy with amphotericin should always be administered.
-
Amphotericin remains the primary medical therapy for this disease; however, there is limited emerging evidence to suggest that echinocandins can be used in combination with amphotericin for improved treatment of severe rhinocerebral zygomyocosis. Posaconazole has a role as salvage therapy in zygomycosis, but should not be used as the sole primary treatment.
The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant.
This icon represents the patient's case. Each paragraph that follows represents the discussant's thoughts.
Acknowledgements
The authors are indebted to Dr Glenn Roberson at the Department of Radiology, University of Alabama at Birmingham, for providing the radiographic images; to Dr Aleodor Andea at the Department of Pathology, University of Alabama at Birmingham, for providing the pathology images; and to Dr. Crysten Brinkley at the Department of Neurology at the University of Alabama at Birmingham for her assistance with this case presentation.
Disclosure: Nothing to report.
- ,,,.Mucormycosis: emerging prominence of cutaneous infections.Clin Infect Dis.1994;19:67–76.
- ,,,.Zygomycosis in the 1990s in a tertiary‐care cancer center.Clin Infect Dis.2000;30:851–856.
- ,,, et al.Mucormycosis during deferoxamine therapy is a siderophore‐mediated infection. In vitro and in vivo animal studies.J Clin Invest.1993;91:1979–1986.
- ,,, et al.Epidemiology and outcome of zygomycosis: a review of 929 reported cases.Clin Infect Dis.2005;41:634–653.
- ,,,,,.Cutaneous mucormycosis of the head and neck with parotid gland involvement: first report of a case.Ear Nose Throat J.2004;83:282–286.
- ,,,,,.A successful combined endovascular and surgical treatment of a cranial base mucormycosis with an associated internal carotid artery pseudoaneurysm.Neurosurgery.2009;65:733–740.
- ,.Judgment under uncertainty: heuristics and biases.Science.1974;185:1124–1131.
- ,,,,.Clinical problem‐solving. Anchors away.N Engl J Med.2007;356:504–509.
- ,,,.Clinical problem‐solving. Empirically incorrect.N Engl J Med.2006;354:509–514.
- ,,.Dealing with uncertainty, risks, and tradeoffs in clinical decisions. A cognitive science approach.Ann Intern Med.1988;108:435–449.
- ,,.Fatal strokes in patients with rhino‐orbito‐cerebral mucormycosis and associated vasculopathy.Scand J Infect Dis.2004;36:643–648.
- ,,, et al.Combination polyene‐caspofungin treatment of rhino‐orbital‐cerebral mucormycosis.Clin Infect Dis.2008;47:364–371.
- ,,,,.Posaconazole is effective as salvage therapy in zygomycosis: a retrospective summary of 91 cases.Clin Infect Dis.2006;42:e61–e65.
- ,,,.Mucormycosis: emerging prominence of cutaneous infections.Clin Infect Dis.1994;19:67–76.
- ,,,.Zygomycosis in the 1990s in a tertiary‐care cancer center.Clin Infect Dis.2000;30:851–856.
- ,,, et al.Mucormycosis during deferoxamine therapy is a siderophore‐mediated infection. In vitro and in vivo animal studies.J Clin Invest.1993;91:1979–1986.
- ,,, et al.Epidemiology and outcome of zygomycosis: a review of 929 reported cases.Clin Infect Dis.2005;41:634–653.
- ,,,,,.Cutaneous mucormycosis of the head and neck with parotid gland involvement: first report of a case.Ear Nose Throat J.2004;83:282–286.
- ,,,,,.A successful combined endovascular and surgical treatment of a cranial base mucormycosis with an associated internal carotid artery pseudoaneurysm.Neurosurgery.2009;65:733–740.
- ,.Judgment under uncertainty: heuristics and biases.Science.1974;185:1124–1131.
- ,,,,.Clinical problem‐solving. Anchors away.N Engl J Med.2007;356:504–509.
- ,,,.Clinical problem‐solving. Empirically incorrect.N Engl J Med.2006;354:509–514.
- ,,.Dealing with uncertainty, risks, and tradeoffs in clinical decisions. A cognitive science approach.Ann Intern Med.1988;108:435–449.
- ,,.Fatal strokes in patients with rhino‐orbito‐cerebral mucormycosis and associated vasculopathy.Scand J Infect Dis.2004;36:643–648.
- ,,, et al.Combination polyene‐caspofungin treatment of rhino‐orbital‐cerebral mucormycosis.Clin Infect Dis.2008;47:364–371.
- ,,,,.Posaconazole is effective as salvage therapy in zygomycosis: a retrospective summary of 91 cases.Clin Infect Dis.2006;42:e61–e65.
Successfully Promoted Academic Hospitalists
The growth of academic hospital medicine has been driven by multiple factors including expanding clinical needs, housestaff duty hours' limitations, and an increasing focus on quality and patient safety.1 Hospitalists at academic medical centers frequently assume roles that differ substantially from traditional faculty positions. Academic hospitalists may have predominantly clinical positions, and may be involved in quality improvement and patient safety projects.24 Because of these commitments, many academic hospitalists spend less time on research or educational efforts.1, 5 Many have raised concerns that these unique job descriptions might lead to less time to devote to scholarship and academic pursuits, and consequently greater challenges in the promotions process.2, 5
There are little published data on promotion and tenure in academics, and even less specifically focused on the promotion of hospitalists. Theoretically, promotion should recognize an individual's contribution to his or her institution and field. However, each institution has unique criteria though which faculty achieve promotion. Previous articles addressing specific groups, such as part‐time,6 clinical faculty,79 or clinician‐educators10 may be relevant to hospitalists, as hospitalists may be more likely to fall into these categories. These reports suggest general agreement that promotion committees should consider and weigh clinical and educational work (in addition to scholarly publications) in the promotions process, but assessment methods vary across institutions and the contribution of activities, such as quality improvement, remain unclear. The educator's portfolio has gained momentum as a way to document valued teaching in many institutions,11, 12 but academic hospitalist participation in education may be limited.13
Literature related to the development of Divisions of General Internal Medicine is relevant insofar as similar concerns for promotion were expressed with the growth of their faculty.14, 15 However, its applicability may be limited by differences between roles of hospitalists and more traditional general medicine faculty.
To better understand the factors influencing promotion for academic hospitalists, the Society of General Internal Medicine (SGIM) Academic Hospitalist Task Force (AHTF) undertook a survey of promoted hospitalists who had successfully reached the rank of Associate Professor or higher.
Methods
Development of the Survey
The AHTF is a group of 18 academic hospitalists representing 15 institutions. Draft survey questions were developed by the group and sent to its members for refinement based on group consensus. Three cycles of refinement were performed, and the final survey (Appendix) was converted into an electronic format distributed through SurveyMonkey (SurveyMonkey.com, Portland, OR).
Identification of Survey Recipients
We identified a convenience sample of hospitalists who had been promoted to Associate or Full Professor of Medicine by querying members of the AHTF, the Society of Hospital Medicine (SHM) Academic Committee, and colleagues of academic medical centers with established hospitalist programs. We identified 33 promoted hospitalists.
Each recipient received an email from the AHTF cochairs in January 2009 asking them to complete the survey. If a response was not received in three weeks, a second email was sent. If a response was again not received, an AHTF task‐force member who knew the recipient asked him or her to complete the survey. All responses were received by March 2009.
Data Analysis
We examined responses using descriptive measures. Responses were analyzed across all respondents, as well as between these two subgroups. Statistical analysis with Fisher's exact test was performed using Stata 9.0 (StataCorp, College Station, TX).
Results
Of the 33 hospitalists who received the survey, 26 responded (response rate of 79%). Of these, 25 completed the survey in its entirely and were included in our analysis; 1 did not submit details regarding specific promotion‐related activities. General information regarding the respondents and their programs at the time of their promotion is contained in Table 1.
| |
| No. of institutions represented | 20 |
| Program age | 5.7 years (range 110) |
| Size of hospitalist program at the time of promotion | 10 (range 128) |
| Size of hospitalist program currently | 25 (range 745) |
| Programs that were separate divisions at the time of respondent promotion | 4 (20%) |
| Programs that are now separate divisions | 8 (40%) |
| Programs with 1‐track* promotion system | 2 (10%) |
| Programs with 2‐track promotion system | 8 (40%) |
| Programs with 3‐track promotion system | 9 (45%) |
| Other type of promotion system | 1 (5%) |
| Tenure track* | 8 (32%) |
| Institutions with tenure and promotion criteria that explicitly recognized hospitalist work | 8 (40%) |
The seven nonrespondents were from seven different institutions; however two of these institutions were represented by respondents. One nonrespondent had achieved a rank of Professor (through general medicine); the rest had been promoted to Associate Professor. One nonrespondent is known by the authors to hold a research position.
Ten respondents identified themselves as clinician‐educators (40%), ten as clinician‐administrators (40%), and five as clinician‐researchers (20%). Seventeen (68%) of the promoted hospitalists were not on a tenure track (as defined by them); they were more likely to have administrative or educational roles than a research appointment. Though the majority of self‐identified researchers were among the earliest to have been promoted, there were no statistically significant differences in self‐defined job description between more and less recently promoted hospitalists.
Promoted hospitalists were involved in a diverse range of activities which supported their promotion, including service (eg, institutional committees), education, research, and quality improvement. Nearly all hospitalists surveyed listed teaching and educational activities, and almost all had disseminated scholarly output and some degree of grant funding. Table 2 lists the specific activities in which respondents reported being engaged in each of these domains.
| Activity | Percent of Respondents Engaged in Activity |
|---|---|
| Service | |
| School of Medicine | 56 |
| Department of Medicine | 84 |
| Hospital | 80 |
| Professional societies | 92 |
| Administration | 67 |
| Education | |
| Medical student | 72 |
| Housestaff lectures | 84 |
| Ward/consult attending | 96 |
| Clinic precepting | 40 |
| Course director/curriculum development | 80 |
| Program director (or associate) | 36 |
| Research | |
| Peer‐reviewed publications | 92 |
| Abstract/poster presentations | 80 |
| Invited speaker | 96 |
| Reviewer/editor | 80 |
| Study section | 24 |
| Federal grants | 32 |
| Nonfederal grants (internal and external) | 72 |
| Quality improvement/patient safety | |
| Project member | 36 |
| Project leader | 52 |
| Institutional leadership | 32 |
| Curriculum development | 32 |
A range of individuals assisted the respondents in the promotion process. Twenty‐three (92%) respondents identified the individuals who supported their promotion, and all listed more than one person. Respondents most commonly credited their Section or Division Chief (43%) with facilitating their promotion, followed by Departmental Chairs or Vice/Associate Chairs (22%). Mentors (13%) or peers (8%) were also named. Four respondents (17%) named themselves as the person providing most guidance through the promotions process.
No consistent themes regarding obstacles emerged from free‐text responses to questions about the promotions process. One respondent felt that high clinical expectations made participation in other academic activities a challenge. The only other barriers noted were not being on the radar screen of the Division Chief of GIM, and difficulty identifying external, senior hospitalists to write letters in support of promotion.
When asked about the most important activities supporting their promotion, 24 respondents listed one to two key activities, detailed in Table 3. The most common response was peer‐reviewed publications (33%). Activities related to education and/or teaching were the next most common response (29%), specifically teaching, educational activities, curriculum design, or program director. Research or research funding represented 26% of responses. Valued activities outside of the respondent's institution included national reputation (21%) and service in professional societies (16%). Service or administrative responsibilities were mentioned by 25% of respondents.
| Category of Activity | Frequency of Response* (%) |
|---|---|
| |
| Research | 14 (58) |
| Peer‐reviewed publications | 8 (33) |
| Research | 4 (16) |
| Research funding | 2 (8) |
| Activities outside institution | 8 (33) |
| National reputation | 5 (21) |
| Professional society membership | 3 (13) |
| Education | 7 (29) |
| Teaching | 3 (13) |
| Educational activities | 2 (8) |
| Residency Director | 1 (4) |
| Curriculum development | 1 (4) |
| Service | 6 (25) |
| Service | 3 (13) |
| Administration/leadership of group | 3 (13) |
Discussion
We conducted a unique and comprehensive survey of academic hospitalists who have been promoted since 1995. We identified the most common and important activities contributing to promotion. Contrary to our expectations, survey respondents generally did not report being a hospitalist was a barrier in the promotions process.
Respondents were engaged in a diverse range of activities, including service, education, and research. Interestingly, no one identified him or herself primarily as a clinician. Teaching appeared to be a core component for all surveyed, regardless of academic appointment. Only one felt that her clinical workload as a hospitalist was an obstacle that prevented her from being engaged in other activities important for promotion. With more programs potentially evolving to separate divisions, the issue of being on the radar screen of a General Internal Medicine Division Chief may become less common over time. We hope that as programs mature and the numbers of associate and full professors increase, there will not be difficulty obtaining outside letters.
Although only 23% self‐identified as clinician‐researchers, nearly all had peer‐reviewed publications and other evidence of disseminated scholarly work. Grant funding, both federal and nonfederal, was also common among this group. This finding is consistent with self‐reported activities of a cohort of junior internal medicine faculty followed over three years who were eventually promoted, though the majority of those participants were classified as having either traditional clinician‐educator or clinician‐researcher positions.16
Despite outlining a seemingly clear pathway to promotion for hospitalists, concerns remain. Most importantly, those surveyed seem to have achieved promotion through relatively traditional academic job descriptions. Obtaining or maintaining these types of positions may be difficult as clinical needs at academic centers increase. According to a recent survey of hospitalist faculty,13 over one‐third spend more than 60% of their time on nonteaching clinical services. In that survey, over half of respondents had little or no protected time for scholarly activities. The contrast between this survey's findings and ours raises the question of whether our promoted sample had positions similar to those of most academic hospitalists. Given that the majority of our respondents noted peer‐reviewed publications and grant funding to be among the most important activities for promotion, there may be a dangerous disconnect for junior academic hospitalists who spend the majority of their time in direct patient care. Moreover, the promoted hospitalists in our survey reported relatively less participation in quality improvement/patient safety activities, in contrast to both anecdotal and survey reports that these activities are a major component of many academic hospitalist positions.5, 17 Most academic medical centers do not yet consider achievements in this area in their promotions criteria, potentially creating a barrier for the ranks of clinician quality improvers.1 Thus, significant obstacles to promotion of academic hospitalists may exist.
Leaders in academic hospital medicine are recognizing these potential barriers. A diverse group from major professional societies recently published a summary of the challenges and opportunities for the field of academic hospital medicine.1 Several needs and areas for intervention were identified, including enhanced faculty development and improved documentation of quality improvement activities. The SGIM, the SHM, and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) recently cosponsored an intensive four‐day faculty development course for junior faculty to promote skills necessary for academic hospitalist success. Early reports indicate that this was a success.1820
In addition, the AHTF has developed a Quality Portfolio, paralleling the Educator's Portfolio, that can be used as a tool for documenting quality improvement and patient safety activities in a way that can be useful for career development and promotion.4 Lastly, the Society of Hospital Medicine has hosted the inaugural Academic Hospital Medicine Leadership Summit as part of the national meeting to provide mentorship and professional development opportunities for junior faculty. Our hope is that these opportunities, coupled with the growth of mid‐level and senior leaders in hospital medicine, will provide greater infrastructure for the development and promotion of junior faculty.
Our results may have relevance beyond hospitalist groups. With anticipated further limits on housestaff duty hours, more academic physicians may be asked to fill predominantly clinical roles. In addition, a growing emphasis on quality and patient safety may lead to a more general expansion of academicians who focus on these areas.15
Our survey and methodology have limitations. By including only promoted individuals, we did not survey hospitalists with the most difficulties in the promotions processthose who were not promoted. Thus, we are unable to directly compare successful versus unsuccessful strategies. Identifying nonpromoted academic hospitalists to understand the reasons they were not (or have not yet been) promoted could be a next step in this line of inquiry. Additionally, understanding the attitudes of promotions committees regarding hospitalists, and the clinical and quality improvement roles in which they are engaged, could enhance our current results. Finally, we surveyed a convenience sample of a limited numbers of hospitalists and institutions, and were unable to systematically account for variations in promotions criteria across institutions. However, to our knowledge, this is the most comprehensive study of promotions among academic hospitalists to date. Given the common themes that emerged in terms of activities that supported promotion, mentors, and advice, we believe that our sample was sufficient to identify important themes and advance our understanding of this nascent specialty.
In conclusion, our survey of promoted hospital medicine faculty provides valuable information for junior faculty and hospitalist leaders. Success was found through engaging in a diverse set of activities in the traditional areas of education, service, and scholarship, frequently in conjunction with developing recognition outside of their institutions. While all respondents were clinically active, none described themselves as having purely clinical roles. As academic hospitalist roles evolve, academic leaders will need to provide adequate mentorship, create time for scholarly pursuits, and promote documentation and recognition of nontraditional activities that may nonetheless be worthy of promotion.
- ,,,,,.Challenges and opportunities in academic hospital medicine: report from the academic hospital medicine summit.J Gen Intern Med.2009;24(5):636–641.
- ,,.Hospitalist educators: future of inpatient internal medicine training.Mt Sinai J Med.2008;75(5):436–451.
- ,,,.Hospitalists as emerging leaders in patient safety: lessons learned and future directions.J Patient Saf.2009;5(1):3–8.
- Quality Portfolio—Template and Instructions. Available at: http://www.sgim.org/userfiles/file/AHTF%20QP%20WEB%20TEMPLATE%20INS TRUCTIONS.pdf. Accessed on April 24,2010.
- .An innovative approach to support hospitalist physicians toward academic success.J Hosp Med.2008;3:314–318.
- ,,,.Institutional policies of U.S. medical schools regarding tenure, promotion, and benefits for part‐time faculty.Acad Med.2000;75(8):846–849.
- ,,,,,.Revising appointment, promotion, and tenure procedures to incorporate an expanded definition of scholarship: the University of Kentucky College of Medicine experience.Acad Med.2000;75(9)913–924.
- ,,,.Attitudes of clinical faculty about career progress, career success and recognition, and commitment to academic medicine. Results of a survey.Arch Intern Med.2000;160(17):2625–2629.
- ,,, et al.Promotion criteria for clinician‐educators.J Gen Intern Med.2003;18(9):711–716.
- ,,,.Documentation systems for educators seeking academic promotion in U.S. medical schools.Acad Med.2004;79(8):783–790.
- ,,,.Faculty development: academic opportunities for emergency medicine faculty on education career tracks.Acad Emerg Med.2003;10(10):1113–1117.
- ,,,.Burnout and internal medicine resident work hours restrictions.Arch Intern Med.2005;165(22):2595–2600.
- ,.Development of a Division of General Medicine in a Department of Internal Medicine.J Med Ed.1981;56:390–396.
- .The evolution of departments of medicine.N Engl J Med.1980;303(9):489–496.
- ,.Clinicians in quality improvement: a new career pathway in academic medicine.JAMA.2009;301(7):766–768.
- ,,.A time to be promoted. The prospective study of promotion in academia.J Gen Intern Med.2006;21(2):123–129.
- Academic Hospitalist Academy. Available at: http://www.sgim.org/index. cfm?pageId=815. Accessed on April 24,2010.
- .Reflections on the Academic Hospitalist Academy.SGIM Forum.2010;33(1):5.
- .The Academic Hospitalist Academy: Get anchored, equipped, and energized.SGIM Forum.2010;33(1):5–6.
- .Four formative days in the life of an academic hospitalist: the Academic Hospitalist Academy.SGIM Forum.2010;33(1):6.
The growth of academic hospital medicine has been driven by multiple factors including expanding clinical needs, housestaff duty hours' limitations, and an increasing focus on quality and patient safety.1 Hospitalists at academic medical centers frequently assume roles that differ substantially from traditional faculty positions. Academic hospitalists may have predominantly clinical positions, and may be involved in quality improvement and patient safety projects.24 Because of these commitments, many academic hospitalists spend less time on research or educational efforts.1, 5 Many have raised concerns that these unique job descriptions might lead to less time to devote to scholarship and academic pursuits, and consequently greater challenges in the promotions process.2, 5
There are little published data on promotion and tenure in academics, and even less specifically focused on the promotion of hospitalists. Theoretically, promotion should recognize an individual's contribution to his or her institution and field. However, each institution has unique criteria though which faculty achieve promotion. Previous articles addressing specific groups, such as part‐time,6 clinical faculty,79 or clinician‐educators10 may be relevant to hospitalists, as hospitalists may be more likely to fall into these categories. These reports suggest general agreement that promotion committees should consider and weigh clinical and educational work (in addition to scholarly publications) in the promotions process, but assessment methods vary across institutions and the contribution of activities, such as quality improvement, remain unclear. The educator's portfolio has gained momentum as a way to document valued teaching in many institutions,11, 12 but academic hospitalist participation in education may be limited.13
Literature related to the development of Divisions of General Internal Medicine is relevant insofar as similar concerns for promotion were expressed with the growth of their faculty.14, 15 However, its applicability may be limited by differences between roles of hospitalists and more traditional general medicine faculty.
To better understand the factors influencing promotion for academic hospitalists, the Society of General Internal Medicine (SGIM) Academic Hospitalist Task Force (AHTF) undertook a survey of promoted hospitalists who had successfully reached the rank of Associate Professor or higher.
Methods
Development of the Survey
The AHTF is a group of 18 academic hospitalists representing 15 institutions. Draft survey questions were developed by the group and sent to its members for refinement based on group consensus. Three cycles of refinement were performed, and the final survey (Appendix) was converted into an electronic format distributed through SurveyMonkey (SurveyMonkey.com, Portland, OR).
Identification of Survey Recipients
We identified a convenience sample of hospitalists who had been promoted to Associate or Full Professor of Medicine by querying members of the AHTF, the Society of Hospital Medicine (SHM) Academic Committee, and colleagues of academic medical centers with established hospitalist programs. We identified 33 promoted hospitalists.
Each recipient received an email from the AHTF cochairs in January 2009 asking them to complete the survey. If a response was not received in three weeks, a second email was sent. If a response was again not received, an AHTF task‐force member who knew the recipient asked him or her to complete the survey. All responses were received by March 2009.
Data Analysis
We examined responses using descriptive measures. Responses were analyzed across all respondents, as well as between these two subgroups. Statistical analysis with Fisher's exact test was performed using Stata 9.0 (StataCorp, College Station, TX).
Results
Of the 33 hospitalists who received the survey, 26 responded (response rate of 79%). Of these, 25 completed the survey in its entirely and were included in our analysis; 1 did not submit details regarding specific promotion‐related activities. General information regarding the respondents and their programs at the time of their promotion is contained in Table 1.
| |
| No. of institutions represented | 20 |
| Program age | 5.7 years (range 110) |
| Size of hospitalist program at the time of promotion | 10 (range 128) |
| Size of hospitalist program currently | 25 (range 745) |
| Programs that were separate divisions at the time of respondent promotion | 4 (20%) |
| Programs that are now separate divisions | 8 (40%) |
| Programs with 1‐track* promotion system | 2 (10%) |
| Programs with 2‐track promotion system | 8 (40%) |
| Programs with 3‐track promotion system | 9 (45%) |
| Other type of promotion system | 1 (5%) |
| Tenure track* | 8 (32%) |
| Institutions with tenure and promotion criteria that explicitly recognized hospitalist work | 8 (40%) |
The seven nonrespondents were from seven different institutions; however two of these institutions were represented by respondents. One nonrespondent had achieved a rank of Professor (through general medicine); the rest had been promoted to Associate Professor. One nonrespondent is known by the authors to hold a research position.
Ten respondents identified themselves as clinician‐educators (40%), ten as clinician‐administrators (40%), and five as clinician‐researchers (20%). Seventeen (68%) of the promoted hospitalists were not on a tenure track (as defined by them); they were more likely to have administrative or educational roles than a research appointment. Though the majority of self‐identified researchers were among the earliest to have been promoted, there were no statistically significant differences in self‐defined job description between more and less recently promoted hospitalists.
Promoted hospitalists were involved in a diverse range of activities which supported their promotion, including service (eg, institutional committees), education, research, and quality improvement. Nearly all hospitalists surveyed listed teaching and educational activities, and almost all had disseminated scholarly output and some degree of grant funding. Table 2 lists the specific activities in which respondents reported being engaged in each of these domains.
| Activity | Percent of Respondents Engaged in Activity |
|---|---|
| Service | |
| School of Medicine | 56 |
| Department of Medicine | 84 |
| Hospital | 80 |
| Professional societies | 92 |
| Administration | 67 |
| Education | |
| Medical student | 72 |
| Housestaff lectures | 84 |
| Ward/consult attending | 96 |
| Clinic precepting | 40 |
| Course director/curriculum development | 80 |
| Program director (or associate) | 36 |
| Research | |
| Peer‐reviewed publications | 92 |
| Abstract/poster presentations | 80 |
| Invited speaker | 96 |
| Reviewer/editor | 80 |
| Study section | 24 |
| Federal grants | 32 |
| Nonfederal grants (internal and external) | 72 |
| Quality improvement/patient safety | |
| Project member | 36 |
| Project leader | 52 |
| Institutional leadership | 32 |
| Curriculum development | 32 |
A range of individuals assisted the respondents in the promotion process. Twenty‐three (92%) respondents identified the individuals who supported their promotion, and all listed more than one person. Respondents most commonly credited their Section or Division Chief (43%) with facilitating their promotion, followed by Departmental Chairs or Vice/Associate Chairs (22%). Mentors (13%) or peers (8%) were also named. Four respondents (17%) named themselves as the person providing most guidance through the promotions process.
No consistent themes regarding obstacles emerged from free‐text responses to questions about the promotions process. One respondent felt that high clinical expectations made participation in other academic activities a challenge. The only other barriers noted were not being on the radar screen of the Division Chief of GIM, and difficulty identifying external, senior hospitalists to write letters in support of promotion.
When asked about the most important activities supporting their promotion, 24 respondents listed one to two key activities, detailed in Table 3. The most common response was peer‐reviewed publications (33%). Activities related to education and/or teaching were the next most common response (29%), specifically teaching, educational activities, curriculum design, or program director. Research or research funding represented 26% of responses. Valued activities outside of the respondent's institution included national reputation (21%) and service in professional societies (16%). Service or administrative responsibilities were mentioned by 25% of respondents.
| Category of Activity | Frequency of Response* (%) |
|---|---|
| |
| Research | 14 (58) |
| Peer‐reviewed publications | 8 (33) |
| Research | 4 (16) |
| Research funding | 2 (8) |
| Activities outside institution | 8 (33) |
| National reputation | 5 (21) |
| Professional society membership | 3 (13) |
| Education | 7 (29) |
| Teaching | 3 (13) |
| Educational activities | 2 (8) |
| Residency Director | 1 (4) |
| Curriculum development | 1 (4) |
| Service | 6 (25) |
| Service | 3 (13) |
| Administration/leadership of group | 3 (13) |
Discussion
We conducted a unique and comprehensive survey of academic hospitalists who have been promoted since 1995. We identified the most common and important activities contributing to promotion. Contrary to our expectations, survey respondents generally did not report being a hospitalist was a barrier in the promotions process.
Respondents were engaged in a diverse range of activities, including service, education, and research. Interestingly, no one identified him or herself primarily as a clinician. Teaching appeared to be a core component for all surveyed, regardless of academic appointment. Only one felt that her clinical workload as a hospitalist was an obstacle that prevented her from being engaged in other activities important for promotion. With more programs potentially evolving to separate divisions, the issue of being on the radar screen of a General Internal Medicine Division Chief may become less common over time. We hope that as programs mature and the numbers of associate and full professors increase, there will not be difficulty obtaining outside letters.
Although only 23% self‐identified as clinician‐researchers, nearly all had peer‐reviewed publications and other evidence of disseminated scholarly work. Grant funding, both federal and nonfederal, was also common among this group. This finding is consistent with self‐reported activities of a cohort of junior internal medicine faculty followed over three years who were eventually promoted, though the majority of those participants were classified as having either traditional clinician‐educator or clinician‐researcher positions.16
Despite outlining a seemingly clear pathway to promotion for hospitalists, concerns remain. Most importantly, those surveyed seem to have achieved promotion through relatively traditional academic job descriptions. Obtaining or maintaining these types of positions may be difficult as clinical needs at academic centers increase. According to a recent survey of hospitalist faculty,13 over one‐third spend more than 60% of their time on nonteaching clinical services. In that survey, over half of respondents had little or no protected time for scholarly activities. The contrast between this survey's findings and ours raises the question of whether our promoted sample had positions similar to those of most academic hospitalists. Given that the majority of our respondents noted peer‐reviewed publications and grant funding to be among the most important activities for promotion, there may be a dangerous disconnect for junior academic hospitalists who spend the majority of their time in direct patient care. Moreover, the promoted hospitalists in our survey reported relatively less participation in quality improvement/patient safety activities, in contrast to both anecdotal and survey reports that these activities are a major component of many academic hospitalist positions.5, 17 Most academic medical centers do not yet consider achievements in this area in their promotions criteria, potentially creating a barrier for the ranks of clinician quality improvers.1 Thus, significant obstacles to promotion of academic hospitalists may exist.
Leaders in academic hospital medicine are recognizing these potential barriers. A diverse group from major professional societies recently published a summary of the challenges and opportunities for the field of academic hospital medicine.1 Several needs and areas for intervention were identified, including enhanced faculty development and improved documentation of quality improvement activities. The SGIM, the SHM, and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) recently cosponsored an intensive four‐day faculty development course for junior faculty to promote skills necessary for academic hospitalist success. Early reports indicate that this was a success.1820
In addition, the AHTF has developed a Quality Portfolio, paralleling the Educator's Portfolio, that can be used as a tool for documenting quality improvement and patient safety activities in a way that can be useful for career development and promotion.4 Lastly, the Society of Hospital Medicine has hosted the inaugural Academic Hospital Medicine Leadership Summit as part of the national meeting to provide mentorship and professional development opportunities for junior faculty. Our hope is that these opportunities, coupled with the growth of mid‐level and senior leaders in hospital medicine, will provide greater infrastructure for the development and promotion of junior faculty.
Our results may have relevance beyond hospitalist groups. With anticipated further limits on housestaff duty hours, more academic physicians may be asked to fill predominantly clinical roles. In addition, a growing emphasis on quality and patient safety may lead to a more general expansion of academicians who focus on these areas.15
Our survey and methodology have limitations. By including only promoted individuals, we did not survey hospitalists with the most difficulties in the promotions processthose who were not promoted. Thus, we are unable to directly compare successful versus unsuccessful strategies. Identifying nonpromoted academic hospitalists to understand the reasons they were not (or have not yet been) promoted could be a next step in this line of inquiry. Additionally, understanding the attitudes of promotions committees regarding hospitalists, and the clinical and quality improvement roles in which they are engaged, could enhance our current results. Finally, we surveyed a convenience sample of a limited numbers of hospitalists and institutions, and were unable to systematically account for variations in promotions criteria across institutions. However, to our knowledge, this is the most comprehensive study of promotions among academic hospitalists to date. Given the common themes that emerged in terms of activities that supported promotion, mentors, and advice, we believe that our sample was sufficient to identify important themes and advance our understanding of this nascent specialty.
In conclusion, our survey of promoted hospital medicine faculty provides valuable information for junior faculty and hospitalist leaders. Success was found through engaging in a diverse set of activities in the traditional areas of education, service, and scholarship, frequently in conjunction with developing recognition outside of their institutions. While all respondents were clinically active, none described themselves as having purely clinical roles. As academic hospitalist roles evolve, academic leaders will need to provide adequate mentorship, create time for scholarly pursuits, and promote documentation and recognition of nontraditional activities that may nonetheless be worthy of promotion.
The growth of academic hospital medicine has been driven by multiple factors including expanding clinical needs, housestaff duty hours' limitations, and an increasing focus on quality and patient safety.1 Hospitalists at academic medical centers frequently assume roles that differ substantially from traditional faculty positions. Academic hospitalists may have predominantly clinical positions, and may be involved in quality improvement and patient safety projects.24 Because of these commitments, many academic hospitalists spend less time on research or educational efforts.1, 5 Many have raised concerns that these unique job descriptions might lead to less time to devote to scholarship and academic pursuits, and consequently greater challenges in the promotions process.2, 5
There are little published data on promotion and tenure in academics, and even less specifically focused on the promotion of hospitalists. Theoretically, promotion should recognize an individual's contribution to his or her institution and field. However, each institution has unique criteria though which faculty achieve promotion. Previous articles addressing specific groups, such as part‐time,6 clinical faculty,79 or clinician‐educators10 may be relevant to hospitalists, as hospitalists may be more likely to fall into these categories. These reports suggest general agreement that promotion committees should consider and weigh clinical and educational work (in addition to scholarly publications) in the promotions process, but assessment methods vary across institutions and the contribution of activities, such as quality improvement, remain unclear. The educator's portfolio has gained momentum as a way to document valued teaching in many institutions,11, 12 but academic hospitalist participation in education may be limited.13
Literature related to the development of Divisions of General Internal Medicine is relevant insofar as similar concerns for promotion were expressed with the growth of their faculty.14, 15 However, its applicability may be limited by differences between roles of hospitalists and more traditional general medicine faculty.
To better understand the factors influencing promotion for academic hospitalists, the Society of General Internal Medicine (SGIM) Academic Hospitalist Task Force (AHTF) undertook a survey of promoted hospitalists who had successfully reached the rank of Associate Professor or higher.
Methods
Development of the Survey
The AHTF is a group of 18 academic hospitalists representing 15 institutions. Draft survey questions were developed by the group and sent to its members for refinement based on group consensus. Three cycles of refinement were performed, and the final survey (Appendix) was converted into an electronic format distributed through SurveyMonkey (SurveyMonkey.com, Portland, OR).
Identification of Survey Recipients
We identified a convenience sample of hospitalists who had been promoted to Associate or Full Professor of Medicine by querying members of the AHTF, the Society of Hospital Medicine (SHM) Academic Committee, and colleagues of academic medical centers with established hospitalist programs. We identified 33 promoted hospitalists.
Each recipient received an email from the AHTF cochairs in January 2009 asking them to complete the survey. If a response was not received in three weeks, a second email was sent. If a response was again not received, an AHTF task‐force member who knew the recipient asked him or her to complete the survey. All responses were received by March 2009.
Data Analysis
We examined responses using descriptive measures. Responses were analyzed across all respondents, as well as between these two subgroups. Statistical analysis with Fisher's exact test was performed using Stata 9.0 (StataCorp, College Station, TX).
Results
Of the 33 hospitalists who received the survey, 26 responded (response rate of 79%). Of these, 25 completed the survey in its entirely and were included in our analysis; 1 did not submit details regarding specific promotion‐related activities. General information regarding the respondents and their programs at the time of their promotion is contained in Table 1.
| |
| No. of institutions represented | 20 |
| Program age | 5.7 years (range 110) |
| Size of hospitalist program at the time of promotion | 10 (range 128) |
| Size of hospitalist program currently | 25 (range 745) |
| Programs that were separate divisions at the time of respondent promotion | 4 (20%) |
| Programs that are now separate divisions | 8 (40%) |
| Programs with 1‐track* promotion system | 2 (10%) |
| Programs with 2‐track promotion system | 8 (40%) |
| Programs with 3‐track promotion system | 9 (45%) |
| Other type of promotion system | 1 (5%) |
| Tenure track* | 8 (32%) |
| Institutions with tenure and promotion criteria that explicitly recognized hospitalist work | 8 (40%) |
The seven nonrespondents were from seven different institutions; however two of these institutions were represented by respondents. One nonrespondent had achieved a rank of Professor (through general medicine); the rest had been promoted to Associate Professor. One nonrespondent is known by the authors to hold a research position.
Ten respondents identified themselves as clinician‐educators (40%), ten as clinician‐administrators (40%), and five as clinician‐researchers (20%). Seventeen (68%) of the promoted hospitalists were not on a tenure track (as defined by them); they were more likely to have administrative or educational roles than a research appointment. Though the majority of self‐identified researchers were among the earliest to have been promoted, there were no statistically significant differences in self‐defined job description between more and less recently promoted hospitalists.
Promoted hospitalists were involved in a diverse range of activities which supported their promotion, including service (eg, institutional committees), education, research, and quality improvement. Nearly all hospitalists surveyed listed teaching and educational activities, and almost all had disseminated scholarly output and some degree of grant funding. Table 2 lists the specific activities in which respondents reported being engaged in each of these domains.
| Activity | Percent of Respondents Engaged in Activity |
|---|---|
| Service | |
| School of Medicine | 56 |
| Department of Medicine | 84 |
| Hospital | 80 |
| Professional societies | 92 |
| Administration | 67 |
| Education | |
| Medical student | 72 |
| Housestaff lectures | 84 |
| Ward/consult attending | 96 |
| Clinic precepting | 40 |
| Course director/curriculum development | 80 |
| Program director (or associate) | 36 |
| Research | |
| Peer‐reviewed publications | 92 |
| Abstract/poster presentations | 80 |
| Invited speaker | 96 |
| Reviewer/editor | 80 |
| Study section | 24 |
| Federal grants | 32 |
| Nonfederal grants (internal and external) | 72 |
| Quality improvement/patient safety | |
| Project member | 36 |
| Project leader | 52 |
| Institutional leadership | 32 |
| Curriculum development | 32 |
A range of individuals assisted the respondents in the promotion process. Twenty‐three (92%) respondents identified the individuals who supported their promotion, and all listed more than one person. Respondents most commonly credited their Section or Division Chief (43%) with facilitating their promotion, followed by Departmental Chairs or Vice/Associate Chairs (22%). Mentors (13%) or peers (8%) were also named. Four respondents (17%) named themselves as the person providing most guidance through the promotions process.
No consistent themes regarding obstacles emerged from free‐text responses to questions about the promotions process. One respondent felt that high clinical expectations made participation in other academic activities a challenge. The only other barriers noted were not being on the radar screen of the Division Chief of GIM, and difficulty identifying external, senior hospitalists to write letters in support of promotion.
When asked about the most important activities supporting their promotion, 24 respondents listed one to two key activities, detailed in Table 3. The most common response was peer‐reviewed publications (33%). Activities related to education and/or teaching were the next most common response (29%), specifically teaching, educational activities, curriculum design, or program director. Research or research funding represented 26% of responses. Valued activities outside of the respondent's institution included national reputation (21%) and service in professional societies (16%). Service or administrative responsibilities were mentioned by 25% of respondents.
| Category of Activity | Frequency of Response* (%) |
|---|---|
| |
| Research | 14 (58) |
| Peer‐reviewed publications | 8 (33) |
| Research | 4 (16) |
| Research funding | 2 (8) |
| Activities outside institution | 8 (33) |
| National reputation | 5 (21) |
| Professional society membership | 3 (13) |
| Education | 7 (29) |
| Teaching | 3 (13) |
| Educational activities | 2 (8) |
| Residency Director | 1 (4) |
| Curriculum development | 1 (4) |
| Service | 6 (25) |
| Service | 3 (13) |
| Administration/leadership of group | 3 (13) |
Discussion
We conducted a unique and comprehensive survey of academic hospitalists who have been promoted since 1995. We identified the most common and important activities contributing to promotion. Contrary to our expectations, survey respondents generally did not report being a hospitalist was a barrier in the promotions process.
Respondents were engaged in a diverse range of activities, including service, education, and research. Interestingly, no one identified him or herself primarily as a clinician. Teaching appeared to be a core component for all surveyed, regardless of academic appointment. Only one felt that her clinical workload as a hospitalist was an obstacle that prevented her from being engaged in other activities important for promotion. With more programs potentially evolving to separate divisions, the issue of being on the radar screen of a General Internal Medicine Division Chief may become less common over time. We hope that as programs mature and the numbers of associate and full professors increase, there will not be difficulty obtaining outside letters.
Although only 23% self‐identified as clinician‐researchers, nearly all had peer‐reviewed publications and other evidence of disseminated scholarly work. Grant funding, both federal and nonfederal, was also common among this group. This finding is consistent with self‐reported activities of a cohort of junior internal medicine faculty followed over three years who were eventually promoted, though the majority of those participants were classified as having either traditional clinician‐educator or clinician‐researcher positions.16
Despite outlining a seemingly clear pathway to promotion for hospitalists, concerns remain. Most importantly, those surveyed seem to have achieved promotion through relatively traditional academic job descriptions. Obtaining or maintaining these types of positions may be difficult as clinical needs at academic centers increase. According to a recent survey of hospitalist faculty,13 over one‐third spend more than 60% of their time on nonteaching clinical services. In that survey, over half of respondents had little or no protected time for scholarly activities. The contrast between this survey's findings and ours raises the question of whether our promoted sample had positions similar to those of most academic hospitalists. Given that the majority of our respondents noted peer‐reviewed publications and grant funding to be among the most important activities for promotion, there may be a dangerous disconnect for junior academic hospitalists who spend the majority of their time in direct patient care. Moreover, the promoted hospitalists in our survey reported relatively less participation in quality improvement/patient safety activities, in contrast to both anecdotal and survey reports that these activities are a major component of many academic hospitalist positions.5, 17 Most academic medical centers do not yet consider achievements in this area in their promotions criteria, potentially creating a barrier for the ranks of clinician quality improvers.1 Thus, significant obstacles to promotion of academic hospitalists may exist.
Leaders in academic hospital medicine are recognizing these potential barriers. A diverse group from major professional societies recently published a summary of the challenges and opportunities for the field of academic hospital medicine.1 Several needs and areas for intervention were identified, including enhanced faculty development and improved documentation of quality improvement activities. The SGIM, the SHM, and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) recently cosponsored an intensive four‐day faculty development course for junior faculty to promote skills necessary for academic hospitalist success. Early reports indicate that this was a success.1820
In addition, the AHTF has developed a Quality Portfolio, paralleling the Educator's Portfolio, that can be used as a tool for documenting quality improvement and patient safety activities in a way that can be useful for career development and promotion.4 Lastly, the Society of Hospital Medicine has hosted the inaugural Academic Hospital Medicine Leadership Summit as part of the national meeting to provide mentorship and professional development opportunities for junior faculty. Our hope is that these opportunities, coupled with the growth of mid‐level and senior leaders in hospital medicine, will provide greater infrastructure for the development and promotion of junior faculty.
Our results may have relevance beyond hospitalist groups. With anticipated further limits on housestaff duty hours, more academic physicians may be asked to fill predominantly clinical roles. In addition, a growing emphasis on quality and patient safety may lead to a more general expansion of academicians who focus on these areas.15
Our survey and methodology have limitations. By including only promoted individuals, we did not survey hospitalists with the most difficulties in the promotions processthose who were not promoted. Thus, we are unable to directly compare successful versus unsuccessful strategies. Identifying nonpromoted academic hospitalists to understand the reasons they were not (or have not yet been) promoted could be a next step in this line of inquiry. Additionally, understanding the attitudes of promotions committees regarding hospitalists, and the clinical and quality improvement roles in which they are engaged, could enhance our current results. Finally, we surveyed a convenience sample of a limited numbers of hospitalists and institutions, and were unable to systematically account for variations in promotions criteria across institutions. However, to our knowledge, this is the most comprehensive study of promotions among academic hospitalists to date. Given the common themes that emerged in terms of activities that supported promotion, mentors, and advice, we believe that our sample was sufficient to identify important themes and advance our understanding of this nascent specialty.
In conclusion, our survey of promoted hospital medicine faculty provides valuable information for junior faculty and hospitalist leaders. Success was found through engaging in a diverse set of activities in the traditional areas of education, service, and scholarship, frequently in conjunction with developing recognition outside of their institutions. While all respondents were clinically active, none described themselves as having purely clinical roles. As academic hospitalist roles evolve, academic leaders will need to provide adequate mentorship, create time for scholarly pursuits, and promote documentation and recognition of nontraditional activities that may nonetheless be worthy of promotion.
- ,,,,,.Challenges and opportunities in academic hospital medicine: report from the academic hospital medicine summit.J Gen Intern Med.2009;24(5):636–641.
- ,,.Hospitalist educators: future of inpatient internal medicine training.Mt Sinai J Med.2008;75(5):436–451.
- ,,,.Hospitalists as emerging leaders in patient safety: lessons learned and future directions.J Patient Saf.2009;5(1):3–8.
- Quality Portfolio—Template and Instructions. Available at: http://www.sgim.org/userfiles/file/AHTF%20QP%20WEB%20TEMPLATE%20INS TRUCTIONS.pdf. Accessed on April 24,2010.
- .An innovative approach to support hospitalist physicians toward academic success.J Hosp Med.2008;3:314–318.
- ,,,.Institutional policies of U.S. medical schools regarding tenure, promotion, and benefits for part‐time faculty.Acad Med.2000;75(8):846–849.
- ,,,,,.Revising appointment, promotion, and tenure procedures to incorporate an expanded definition of scholarship: the University of Kentucky College of Medicine experience.Acad Med.2000;75(9)913–924.
- ,,,.Attitudes of clinical faculty about career progress, career success and recognition, and commitment to academic medicine. Results of a survey.Arch Intern Med.2000;160(17):2625–2629.
- ,,, et al.Promotion criteria for clinician‐educators.J Gen Intern Med.2003;18(9):711–716.
- ,,,.Documentation systems for educators seeking academic promotion in U.S. medical schools.Acad Med.2004;79(8):783–790.
- ,,,.Faculty development: academic opportunities for emergency medicine faculty on education career tracks.Acad Emerg Med.2003;10(10):1113–1117.
- ,,,.Burnout and internal medicine resident work hours restrictions.Arch Intern Med.2005;165(22):2595–2600.
- ,.Development of a Division of General Medicine in a Department of Internal Medicine.J Med Ed.1981;56:390–396.
- .The evolution of departments of medicine.N Engl J Med.1980;303(9):489–496.
- ,.Clinicians in quality improvement: a new career pathway in academic medicine.JAMA.2009;301(7):766–768.
- ,,.A time to be promoted. The prospective study of promotion in academia.J Gen Intern Med.2006;21(2):123–129.
- Academic Hospitalist Academy. Available at: http://www.sgim.org/index. cfm?pageId=815. Accessed on April 24,2010.
- .Reflections on the Academic Hospitalist Academy.SGIM Forum.2010;33(1):5.
- .The Academic Hospitalist Academy: Get anchored, equipped, and energized.SGIM Forum.2010;33(1):5–6.
- .Four formative days in the life of an academic hospitalist: the Academic Hospitalist Academy.SGIM Forum.2010;33(1):6.
- ,,,,,.Challenges and opportunities in academic hospital medicine: report from the academic hospital medicine summit.J Gen Intern Med.2009;24(5):636–641.
- ,,.Hospitalist educators: future of inpatient internal medicine training.Mt Sinai J Med.2008;75(5):436–451.
- ,,,.Hospitalists as emerging leaders in patient safety: lessons learned and future directions.J Patient Saf.2009;5(1):3–8.
- Quality Portfolio—Template and Instructions. Available at: http://www.sgim.org/userfiles/file/AHTF%20QP%20WEB%20TEMPLATE%20INS TRUCTIONS.pdf. Accessed on April 24,2010.
- .An innovative approach to support hospitalist physicians toward academic success.J Hosp Med.2008;3:314–318.
- ,,,.Institutional policies of U.S. medical schools regarding tenure, promotion, and benefits for part‐time faculty.Acad Med.2000;75(8):846–849.
- ,,,,,.Revising appointment, promotion, and tenure procedures to incorporate an expanded definition of scholarship: the University of Kentucky College of Medicine experience.Acad Med.2000;75(9)913–924.
- ,,,.Attitudes of clinical faculty about career progress, career success and recognition, and commitment to academic medicine. Results of a survey.Arch Intern Med.2000;160(17):2625–2629.
- ,,, et al.Promotion criteria for clinician‐educators.J Gen Intern Med.2003;18(9):711–716.
- ,,,.Documentation systems for educators seeking academic promotion in U.S. medical schools.Acad Med.2004;79(8):783–790.
- ,,,.Faculty development: academic opportunities for emergency medicine faculty on education career tracks.Acad Emerg Med.2003;10(10):1113–1117.
- ,,,.Burnout and internal medicine resident work hours restrictions.Arch Intern Med.2005;165(22):2595–2600.
- ,.Development of a Division of General Medicine in a Department of Internal Medicine.J Med Ed.1981;56:390–396.
- .The evolution of departments of medicine.N Engl J Med.1980;303(9):489–496.
- ,.Clinicians in quality improvement: a new career pathway in academic medicine.JAMA.2009;301(7):766–768.
- ,,.A time to be promoted. The prospective study of promotion in academia.J Gen Intern Med.2006;21(2):123–129.
- Academic Hospitalist Academy. Available at: http://www.sgim.org/index. cfm?pageId=815. Accessed on April 24,2010.
- .Reflections on the Academic Hospitalist Academy.SGIM Forum.2010;33(1):5.
- .The Academic Hospitalist Academy: Get anchored, equipped, and energized.SGIM Forum.2010;33(1):5–6.
- .Four formative days in the life of an academic hospitalist: the Academic Hospitalist Academy.SGIM Forum.2010;33(1):6.
Copyright © 2011 Society of Hospital Medicine
It’s 5 pm Friday; the caller thinks he has strep—Do you write that script?
Should you treat a symptomatic patient by phone when his child has confirmed strep throat?1 A recent Clinical Inquiry to The Journal of Family Practice posed this common question. The respondent answered by insisting on having the patient come into the office.
While we agree that a thorough examination is preferred over telephone management, we also believe that physicians need a strategy to apply when the adult patient cannot come to the office. Specifically, what do you do when the call comes in on a Friday evening, and the office is closed on Saturdays? What do you do when the patient is currently out of town? What do you do when the patient will not agree to an office visit?
Consider this tool for that late Friday call
If an adult patient caller has a son or daughter who currently has strep, the prior probability of strep causing the parent’s sore throat increases dramatically. While we know of no studies that document this precise situation, we would estimate that the prior probability would increase to about 50%. (The authors of the Clinical Inquiry assumed a population prevalence of 10%.1)
In such a situation, you may want to consider a tool that helps to estimate the probability of strep based on taking a history.2 Using this scoring system, you would give a score of 0 to 3 (absent, mild, moderate, severe) for each of 3 symptoms—fever, difficulty swallowing, and cough. You would add the scores for difficulty swallowing and fever and then subtract the cough score. We recommend a score of +2 or greater as a reasonable cutoff for telephone management in this situation (sensitivity = 85%, specificity = 42%) (TABLE).2
This scoring system, while less well known than our examination based score,3 performed quite well. The ROC curve areas did not significantly differ from the areas of the scoring rule, which includes physical examination.
TABLE
Should you write that prescription? Adult sore throat telephone scoring system helps you decide2
| Add the scores for fever and difficulty swallowing. Then subtract the cough score. Consider writing a prescription for scores of +2 or greater. | ||||
|---|---|---|---|---|
| SEVERITY | ||||
| VARIABLES | ABSENT | MILD | MODERATE | SEVERE |
| Fever | 0 | +1 | +2 | +3 |
| Difficulty in swallowing | 0 | +1 | +2 | +3 |
| Cough | 0 | +1 | +2 | +3 |
Unpublished data explain why this tool works
Sore throat patients cluster their signs and symptoms into 3 groupings: fever, viral symptoms (cough and coryza), and inflammatory signs and symptoms (exudates, adenopathy, and difficulty swallowing). Our unpublished data indicate that the severity of difficulty swallowing correlates with the severity of tonsillar exudates. Thus, the “telephone score” also correlates highly with the examination based score.
Keep in mind these 2 important caveats
If you recommend initial management for a sore throat patient, you (or someone on the nursing staff) should explain to the patient that if symptoms worsen, he should return for further evaluation. Even with antibiotic treatment, some patients develop peritonsillar abscess or Lemierre’s syndrome.
In addition, this telephone scoring tool is restricted to adult patients. Adult pharyngitis and pediatric pharyngitis, while similar, have significant differences. We developed the telephone score using adult data, and we have no assurance that it would work for children.
That said, we submit that family physicians should use this telephone score when an office visit is not feasible. We further suggest that you can use the telephone score to reassure patients that it’s unlikely that they have strep throat. While we prefer seeing patients with sore throat, we need a rational strategy to apply to adults who cannot, or will not, come to the office.
ANSWER:
A) Prevent nonsuppurative complications.
B) Prevent suppurative complications.
C) Decrease the duration of symptoms.
D) Prevent transmission to others.
A, B, C, and D are, of course, all reasons why we treat strep throat. The evidence in support of each of them, however, varies greatly. Consider the following:
- Of the nonsuppurative complications, we only have data that we can decrease the probability of rheumatic fever. Rheumatic fever in the US occurs rarely, and thus no longer has a major influence on our decision-making process. A recent review estimated the number needed to treat (NNT) for benefit as 3000 to 4000.4
- While we believe that early treatment decreases suppurative complications, there is no good data on the impact of early treatment on decreasing suppurative complications. The most recent estimate that we can find for NNT to prevent suppurative complications is 27.4 While uncommon, suppurative complications cause great pain, high health-care costs, and occasionally, death.
- Antibiotics clearly decrease symptom duration for strep throat.5 In the Zwart study, symptoms resolved 2 days sooner when patients were treated with penicillin for 7 days. Since patients call us because they feel bad, decreasing symptom duration is the most important reason to start narrow spectrum antibiotics promptly.
- We do not have great data on the preventive benefit to close contacts. We do know that strep infections have high infectivity.
Correspondence
Robert M Centor, MD, FOT720, 1530 3rd Ave S, Birmingham, AL 35294-3407; [email protected].
1. Sheridan E, Ludwig J, Helmen J. Should you treat a symptomatic patient by phone when his child has confirmed strep throat? J Fam Pract 2007;56:234-235.
2. Clancy CM, Centor RM, Campbell MS, Dalton HP. Rational decision making based on history: adult sore throats. J Gen Intern Med 1988;3:213-217.
3. Centor RM, Witherspoon JM, Dalton HP, Brody CE. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981;1:239-246.
4. Graham TAD. Diagnosis and treatment of pharyngitis in adults. CJEM 2002;4:429-430.
5. Zwart S, Sachs A, Ruijs GJ, Gubbels JW, Hoes AW, Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment of placebo in adults. BMJ 2000;320:150-154.
Should you treat a symptomatic patient by phone when his child has confirmed strep throat?1 A recent Clinical Inquiry to The Journal of Family Practice posed this common question. The respondent answered by insisting on having the patient come into the office.
While we agree that a thorough examination is preferred over telephone management, we also believe that physicians need a strategy to apply when the adult patient cannot come to the office. Specifically, what do you do when the call comes in on a Friday evening, and the office is closed on Saturdays? What do you do when the patient is currently out of town? What do you do when the patient will not agree to an office visit?
Consider this tool for that late Friday call
If an adult patient caller has a son or daughter who currently has strep, the prior probability of strep causing the parent’s sore throat increases dramatically. While we know of no studies that document this precise situation, we would estimate that the prior probability would increase to about 50%. (The authors of the Clinical Inquiry assumed a population prevalence of 10%.1)
In such a situation, you may want to consider a tool that helps to estimate the probability of strep based on taking a history.2 Using this scoring system, you would give a score of 0 to 3 (absent, mild, moderate, severe) for each of 3 symptoms—fever, difficulty swallowing, and cough. You would add the scores for difficulty swallowing and fever and then subtract the cough score. We recommend a score of +2 or greater as a reasonable cutoff for telephone management in this situation (sensitivity = 85%, specificity = 42%) (TABLE).2
This scoring system, while less well known than our examination based score,3 performed quite well. The ROC curve areas did not significantly differ from the areas of the scoring rule, which includes physical examination.
TABLE
Should you write that prescription? Adult sore throat telephone scoring system helps you decide2
| Add the scores for fever and difficulty swallowing. Then subtract the cough score. Consider writing a prescription for scores of +2 or greater. | ||||
|---|---|---|---|---|
| SEVERITY | ||||
| VARIABLES | ABSENT | MILD | MODERATE | SEVERE |
| Fever | 0 | +1 | +2 | +3 |
| Difficulty in swallowing | 0 | +1 | +2 | +3 |
| Cough | 0 | +1 | +2 | +3 |
Unpublished data explain why this tool works
Sore throat patients cluster their signs and symptoms into 3 groupings: fever, viral symptoms (cough and coryza), and inflammatory signs and symptoms (exudates, adenopathy, and difficulty swallowing). Our unpublished data indicate that the severity of difficulty swallowing correlates with the severity of tonsillar exudates. Thus, the “telephone score” also correlates highly with the examination based score.
Keep in mind these 2 important caveats
If you recommend initial management for a sore throat patient, you (or someone on the nursing staff) should explain to the patient that if symptoms worsen, he should return for further evaluation. Even with antibiotic treatment, some patients develop peritonsillar abscess or Lemierre’s syndrome.
In addition, this telephone scoring tool is restricted to adult patients. Adult pharyngitis and pediatric pharyngitis, while similar, have significant differences. We developed the telephone score using adult data, and we have no assurance that it would work for children.
That said, we submit that family physicians should use this telephone score when an office visit is not feasible. We further suggest that you can use the telephone score to reassure patients that it’s unlikely that they have strep throat. While we prefer seeing patients with sore throat, we need a rational strategy to apply to adults who cannot, or will not, come to the office.
ANSWER:
A) Prevent nonsuppurative complications.
B) Prevent suppurative complications.
C) Decrease the duration of symptoms.
D) Prevent transmission to others.
A, B, C, and D are, of course, all reasons why we treat strep throat. The evidence in support of each of them, however, varies greatly. Consider the following:
- Of the nonsuppurative complications, we only have data that we can decrease the probability of rheumatic fever. Rheumatic fever in the US occurs rarely, and thus no longer has a major influence on our decision-making process. A recent review estimated the number needed to treat (NNT) for benefit as 3000 to 4000.4
- While we believe that early treatment decreases suppurative complications, there is no good data on the impact of early treatment on decreasing suppurative complications. The most recent estimate that we can find for NNT to prevent suppurative complications is 27.4 While uncommon, suppurative complications cause great pain, high health-care costs, and occasionally, death.
- Antibiotics clearly decrease symptom duration for strep throat.5 In the Zwart study, symptoms resolved 2 days sooner when patients were treated with penicillin for 7 days. Since patients call us because they feel bad, decreasing symptom duration is the most important reason to start narrow spectrum antibiotics promptly.
- We do not have great data on the preventive benefit to close contacts. We do know that strep infections have high infectivity.
Correspondence
Robert M Centor, MD, FOT720, 1530 3rd Ave S, Birmingham, AL 35294-3407; [email protected].
Should you treat a symptomatic patient by phone when his child has confirmed strep throat?1 A recent Clinical Inquiry to The Journal of Family Practice posed this common question. The respondent answered by insisting on having the patient come into the office.
While we agree that a thorough examination is preferred over telephone management, we also believe that physicians need a strategy to apply when the adult patient cannot come to the office. Specifically, what do you do when the call comes in on a Friday evening, and the office is closed on Saturdays? What do you do when the patient is currently out of town? What do you do when the patient will not agree to an office visit?
Consider this tool for that late Friday call
If an adult patient caller has a son or daughter who currently has strep, the prior probability of strep causing the parent’s sore throat increases dramatically. While we know of no studies that document this precise situation, we would estimate that the prior probability would increase to about 50%. (The authors of the Clinical Inquiry assumed a population prevalence of 10%.1)
In such a situation, you may want to consider a tool that helps to estimate the probability of strep based on taking a history.2 Using this scoring system, you would give a score of 0 to 3 (absent, mild, moderate, severe) for each of 3 symptoms—fever, difficulty swallowing, and cough. You would add the scores for difficulty swallowing and fever and then subtract the cough score. We recommend a score of +2 or greater as a reasonable cutoff for telephone management in this situation (sensitivity = 85%, specificity = 42%) (TABLE).2
This scoring system, while less well known than our examination based score,3 performed quite well. The ROC curve areas did not significantly differ from the areas of the scoring rule, which includes physical examination.
TABLE
Should you write that prescription? Adult sore throat telephone scoring system helps you decide2
| Add the scores for fever and difficulty swallowing. Then subtract the cough score. Consider writing a prescription for scores of +2 or greater. | ||||
|---|---|---|---|---|
| SEVERITY | ||||
| VARIABLES | ABSENT | MILD | MODERATE | SEVERE |
| Fever | 0 | +1 | +2 | +3 |
| Difficulty in swallowing | 0 | +1 | +2 | +3 |
| Cough | 0 | +1 | +2 | +3 |
Unpublished data explain why this tool works
Sore throat patients cluster their signs and symptoms into 3 groupings: fever, viral symptoms (cough and coryza), and inflammatory signs and symptoms (exudates, adenopathy, and difficulty swallowing). Our unpublished data indicate that the severity of difficulty swallowing correlates with the severity of tonsillar exudates. Thus, the “telephone score” also correlates highly with the examination based score.
Keep in mind these 2 important caveats
If you recommend initial management for a sore throat patient, you (or someone on the nursing staff) should explain to the patient that if symptoms worsen, he should return for further evaluation. Even with antibiotic treatment, some patients develop peritonsillar abscess or Lemierre’s syndrome.
In addition, this telephone scoring tool is restricted to adult patients. Adult pharyngitis and pediatric pharyngitis, while similar, have significant differences. We developed the telephone score using adult data, and we have no assurance that it would work for children.
That said, we submit that family physicians should use this telephone score when an office visit is not feasible. We further suggest that you can use the telephone score to reassure patients that it’s unlikely that they have strep throat. While we prefer seeing patients with sore throat, we need a rational strategy to apply to adults who cannot, or will not, come to the office.
ANSWER:
A) Prevent nonsuppurative complications.
B) Prevent suppurative complications.
C) Decrease the duration of symptoms.
D) Prevent transmission to others.
A, B, C, and D are, of course, all reasons why we treat strep throat. The evidence in support of each of them, however, varies greatly. Consider the following:
- Of the nonsuppurative complications, we only have data that we can decrease the probability of rheumatic fever. Rheumatic fever in the US occurs rarely, and thus no longer has a major influence on our decision-making process. A recent review estimated the number needed to treat (NNT) for benefit as 3000 to 4000.4
- While we believe that early treatment decreases suppurative complications, there is no good data on the impact of early treatment on decreasing suppurative complications. The most recent estimate that we can find for NNT to prevent suppurative complications is 27.4 While uncommon, suppurative complications cause great pain, high health-care costs, and occasionally, death.
- Antibiotics clearly decrease symptom duration for strep throat.5 In the Zwart study, symptoms resolved 2 days sooner when patients were treated with penicillin for 7 days. Since patients call us because they feel bad, decreasing symptom duration is the most important reason to start narrow spectrum antibiotics promptly.
- We do not have great data on the preventive benefit to close contacts. We do know that strep infections have high infectivity.
Correspondence
Robert M Centor, MD, FOT720, 1530 3rd Ave S, Birmingham, AL 35294-3407; [email protected].
1. Sheridan E, Ludwig J, Helmen J. Should you treat a symptomatic patient by phone when his child has confirmed strep throat? J Fam Pract 2007;56:234-235.
2. Clancy CM, Centor RM, Campbell MS, Dalton HP. Rational decision making based on history: adult sore throats. J Gen Intern Med 1988;3:213-217.
3. Centor RM, Witherspoon JM, Dalton HP, Brody CE. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981;1:239-246.
4. Graham TAD. Diagnosis and treatment of pharyngitis in adults. CJEM 2002;4:429-430.
5. Zwart S, Sachs A, Ruijs GJ, Gubbels JW, Hoes AW, Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment of placebo in adults. BMJ 2000;320:150-154.
1. Sheridan E, Ludwig J, Helmen J. Should you treat a symptomatic patient by phone when his child has confirmed strep throat? J Fam Pract 2007;56:234-235.
2. Clancy CM, Centor RM, Campbell MS, Dalton HP. Rational decision making based on history: adult sore throats. J Gen Intern Med 1988;3:213-217.
3. Centor RM, Witherspoon JM, Dalton HP, Brody CE. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981;1:239-246.
4. Graham TAD. Diagnosis and treatment of pharyngitis in adults. CJEM 2002;4:429-430.
5. Zwart S, Sachs A, Ruijs GJ, Gubbels JW, Hoes AW, Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment of placebo in adults. BMJ 2000;320:150-154.