The Hospitalist

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

Physician Communication Often Abysmal, Patient Advocate Says

Hospitalists, no doubt, encounter many challenging patient situations that have a lot to do with inappropriate behavior on the part of patients.

But from patient advocate Jackie O’Doherty’s point of view, many tough situations involving the patient-physician dynamic evolve from hospitalists who seem almost incapable of communicating well.

“I’m not saying they’re bad; their communication is not as great as it should be,” she says. “It has to be just giving the information. People get really frustrated when they’re in the hospital and they don’t know what’s going on.”

O’Doherty, a private patient advocate who represents patients in their efforts to get good healthcare at hospitals in New York and New Jersey, says sometimes the communication gaps are staggering.

For example, she represents a patient who had a heart attack and was transferred to a larger center to have open-heart surgery. The surgery went well, but when a Swan catheter was pulled, a plaque was hit and the man had a stroke. Suddenly, his care became a lot more complicated.

A series of specialists came in to see him. One told him that he would be sitting at home at the dinner table and watching football on Thanksgiving. Others gave him a far less rosy outlook. Some told him to drink water; others said not to.

The patient became frustrated, and O’Doherty demanded a meeting to sort out the mess. Eventually, all five of the patient’s doctors, a social worker, and the director of nursing met.

If the hospitalist is supposed to be a unifying force, that hadn’t happened in that case, O’Doherty says. Such cases, while not the norm, are frequent enough to cause concern.

“They’re the quarterbacks, supposedly, of the whole hospital experience, and I haven’t really seen that happen,” she says.

In another case, a patient getting suspect care—O’Doherty had pictures of the patient with a tracheostomy almost falling out of the bed—got a good response.

“They want to do whatever they can to make this work, and that’s a great response,” she says. “The question is, would that have been the response had I not been there?”

She understands the pressures that hospitalists can feel. And she says the system in which the hospitalist is working can matter as much as the hospitalist’s own communication skills.

“If you have a hospital that’s crazy busy, understaffed, and there’s not time,” she says, “that’s what goes first is the communication.”

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

Physician Communication Often Abysmal, Patient Advocate Says

Hospitalists, no doubt, encounter many challenging patient situations that have a lot to do with inappropriate behavior on the part of patients.

But from patient advocate Jackie O’Doherty’s point of view, many tough situations involving the patient-physician dynamic evolve from hospitalists who seem almost incapable of communicating well.

“I’m not saying they’re bad; their communication is not as great as it should be,” she says. “It has to be just giving the information. People get really frustrated when they’re in the hospital and they don’t know what’s going on.”

O’Doherty, a private patient advocate who represents patients in their efforts to get good healthcare at hospitals in New York and New Jersey, says sometimes the communication gaps are staggering.

For example, she represents a patient who had a heart attack and was transferred to a larger center to have open-heart surgery. The surgery went well, but when a Swan catheter was pulled, a plaque was hit and the man had a stroke. Suddenly, his care became a lot more complicated.

A series of specialists came in to see him. One told him that he would be sitting at home at the dinner table and watching football on Thanksgiving. Others gave him a far less rosy outlook. Some told him to drink water; others said not to.

The patient became frustrated, and O’Doherty demanded a meeting to sort out the mess. Eventually, all five of the patient’s doctors, a social worker, and the director of nursing met.

If the hospitalist is supposed to be a unifying force, that hadn’t happened in that case, O’Doherty says. Such cases, while not the norm, are frequent enough to cause concern.

“They’re the quarterbacks, supposedly, of the whole hospital experience, and I haven’t really seen that happen,” she says.

In another case, a patient getting suspect care—O’Doherty had pictures of the patient with a tracheostomy almost falling out of the bed—got a good response.

“They want to do whatever they can to make this work, and that’s a great response,” she says. “The question is, would that have been the response had I not been there?”

She understands the pressures that hospitalists can feel. And she says the system in which the hospitalist is working can matter as much as the hospitalist’s own communication skills.

“If you have a hospital that’s crazy busy, understaffed, and there’s not time,” she says, “that’s what goes first is the communication.”

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

Physician Communication Often Abysmal, Patient Advocate Says

Hospitalists, no doubt, encounter many challenging patient situations that have a lot to do with inappropriate behavior on the part of patients.

But from patient advocate Jackie O’Doherty’s point of view, many tough situations involving the patient-physician dynamic evolve from hospitalists who seem almost incapable of communicating well.

“I’m not saying they’re bad; their communication is not as great as it should be,” she says. “It has to be just giving the information. People get really frustrated when they’re in the hospital and they don’t know what’s going on.”

O’Doherty, a private patient advocate who represents patients in their efforts to get good healthcare at hospitals in New York and New Jersey, says sometimes the communication gaps are staggering.

For example, she represents a patient who had a heart attack and was transferred to a larger center to have open-heart surgery. The surgery went well, but when a Swan catheter was pulled, a plaque was hit and the man had a stroke. Suddenly, his care became a lot more complicated.

A series of specialists came in to see him. One told him that he would be sitting at home at the dinner table and watching football on Thanksgiving. Others gave him a far less rosy outlook. Some told him to drink water; others said not to.

The patient became frustrated, and O’Doherty demanded a meeting to sort out the mess. Eventually, all five of the patient’s doctors, a social worker, and the director of nursing met.

If the hospitalist is supposed to be a unifying force, that hadn’t happened in that case, O’Doherty says. Such cases, while not the norm, are frequent enough to cause concern.

“They’re the quarterbacks, supposedly, of the whole hospital experience, and I haven’t really seen that happen,” she says.

In another case, a patient getting suspect care—O’Doherty had pictures of the patient with a tracheostomy almost falling out of the bed—got a good response.

“They want to do whatever they can to make this work, and that’s a great response,” she says. “The question is, would that have been the response had I not been there?”

She understands the pressures that hospitalists can feel. And she says the system in which the hospitalist is working can matter as much as the hospitalist’s own communication skills.

“If you have a hospital that’s crazy busy, understaffed, and there’s not time,” she says, “that’s what goes first is the communication.”

Brian Harte, MD, SFHM, longtime member of the Society of Hospital Medicine (SHM) and now president of its Board of Directors, was recently named president of Cleveland Clinic Akron General and the Southern Region. He previously served as president of Cleveland Clinic Hillcrest Hospital, the 500-bed flagship for the Cleveland Clinic Health System.

The Hospitalist spoke with Dr. Harte about SHM’s impact on his career and how he sees hospitalists’ roles growing in an evolving health system.

Question: In your speech at Hospital Medicine 2016 in San Diego, you referenced the critical need for hospitalists to explore opportunities to grow both personally and professionally, with SHM as a means of support. How has SHM been that support for you throughout your career from hospitalist to hospitalist leader?

Answer: Hospital medicine is a fantastic career because there are so many opportunities available to us. SHM supports our members in finding their own career paths in a number of ways. For example, Leadership Academy is a valuable resource to develop leadership skills from basic to advanced. More generally, SHM provides many role models and networking opportunities to allow others to learn from hospital medicine professionals and healthcare leaders and help them advance their careers.

Q: Tell us a bit about your expanded role at Cleveland Clinic Health System and how you can leverage SHM as a way to accomplish your goals in this new position.

A: I’ve been at Cleveland Clinic for 12 years, both as a hospitalist and in a number of leadership positions. After having served as president of Cleveland Clinic Hillcrest Hospital, I have a new role now as president of one of their newly acquired hospitals in Akron, Cleveland Clinic Akron General Hospital. Both are community hospitals within the Cleveland Clinic’s integrated healthcare network.

In my new role, I will be overseeing and facilitating the process of integration, and I’m really looking forward to it as a new challenge. I am particularly interested in how other health system and hospital executives who are hospitalists within SHM can help guide me and provide advice on how they have taken on challenges, built bridges, and overseen integration within other organizations.

Q: How does the career path of a hospitalist lend itself to leadership opportunities in a way that some other specialties may not?

A: Being a hospitalist lends itself to an almost limitless set of very interesting and rewarding career paths, both within and outside of pure clinical medicine. Hospitalists tend to have a very close relationship with administration, not just around clinical issues but around performance measurement and management. Because of this, we learn on the job about what leadership really consists of and that effective hospitalists are, by definition, effective leaders. What we do every day, functioning within and ultimately leading high-performing teams, epitomizes experiential leadership development.

SHM is positioned to help guide our members both in identifying their career paths and continuing to follow that path through events like Leadership Academy, Annual Meeting, and other networking opportunities that allow them to meet other hospitalists who have already walked down similar paths. We can help guide each other in terms of avoiding some of the pitfalls we have experienced but also by discovering opportunities and how to take advantage of them.

Q: Moving forward, how can hospitalists demonstrate the value that they add to the healthcare landscape both in practice and from a leadership perspective?

A: Since hospital medicine’s inception, hospitalists have had to show the value that they add to patient care, to hospitals, and to the healthcare system. As we move into an era of alternative payment models (APMs) and healthcare reform, the need to do that for all physicians will only be greater. Hospitalists are extremely well positioned to demonstrate value partly because we have been doing that all along in terms of improving patient care, quality outcomes, or performance measurements that the hospital is keeping track of.

We’re going to have to be stronger advocates for the value we provide to the healthcare system in terms of outcomes for patients as well as cost and efficiency. I know SHM will continue to help our members and the leaders within our membership develop the skills needed to do that.

Brian Harte, MD, SFHM, longtime member of the Society of Hospital Medicine (SHM) and now president of its Board of Directors, was recently named president of Cleveland Clinic Akron General and the Southern Region. He previously served as president of Cleveland Clinic Hillcrest Hospital, the 500-bed flagship for the Cleveland Clinic Health System.

The Hospitalist spoke with Dr. Harte about SHM’s impact on his career and how he sees hospitalists’ roles growing in an evolving health system.

Question: In your speech at Hospital Medicine 2016 in San Diego, you referenced the critical need for hospitalists to explore opportunities to grow both personally and professionally, with SHM as a means of support. How has SHM been that support for you throughout your career from hospitalist to hospitalist leader?

Answer: Hospital medicine is a fantastic career because there are so many opportunities available to us. SHM supports our members in finding their own career paths in a number of ways. For example, Leadership Academy is a valuable resource to develop leadership skills from basic to advanced. More generally, SHM provides many role models and networking opportunities to allow others to learn from hospital medicine professionals and healthcare leaders and help them advance their careers.

Q: Tell us a bit about your expanded role at Cleveland Clinic Health System and how you can leverage SHM as a way to accomplish your goals in this new position.

A: I’ve been at Cleveland Clinic for 12 years, both as a hospitalist and in a number of leadership positions. After having served as president of Cleveland Clinic Hillcrest Hospital, I have a new role now as president of one of their newly acquired hospitals in Akron, Cleveland Clinic Akron General Hospital. Both are community hospitals within the Cleveland Clinic’s integrated healthcare network.

In my new role, I will be overseeing and facilitating the process of integration, and I’m really looking forward to it as a new challenge. I am particularly interested in how other health system and hospital executives who are hospitalists within SHM can help guide me and provide advice on how they have taken on challenges, built bridges, and overseen integration within other organizations.

Q: How does the career path of a hospitalist lend itself to leadership opportunities in a way that some other specialties may not?

A: Being a hospitalist lends itself to an almost limitless set of very interesting and rewarding career paths, both within and outside of pure clinical medicine. Hospitalists tend to have a very close relationship with administration, not just around clinical issues but around performance measurement and management. Because of this, we learn on the job about what leadership really consists of and that effective hospitalists are, by definition, effective leaders. What we do every day, functioning within and ultimately leading high-performing teams, epitomizes experiential leadership development.

SHM is positioned to help guide our members both in identifying their career paths and continuing to follow that path through events like Leadership Academy, Annual Meeting, and other networking opportunities that allow them to meet other hospitalists who have already walked down similar paths. We can help guide each other in terms of avoiding some of the pitfalls we have experienced but also by discovering opportunities and how to take advantage of them.

Q: Moving forward, how can hospitalists demonstrate the value that they add to the healthcare landscape both in practice and from a leadership perspective?

A: Since hospital medicine’s inception, hospitalists have had to show the value that they add to patient care, to hospitals, and to the healthcare system. As we move into an era of alternative payment models (APMs) and healthcare reform, the need to do that for all physicians will only be greater. Hospitalists are extremely well positioned to demonstrate value partly because we have been doing that all along in terms of improving patient care, quality outcomes, or performance measurements that the hospital is keeping track of.

We’re going to have to be stronger advocates for the value we provide to the healthcare system in terms of outcomes for patients as well as cost and efficiency. I know SHM will continue to help our members and the leaders within our membership develop the skills needed to do that.

Brian Harte, MD, SFHM, longtime member of the Society of Hospital Medicine (SHM) and now president of its Board of Directors, was recently named president of Cleveland Clinic Akron General and the Southern Region. He previously served as president of Cleveland Clinic Hillcrest Hospital, the 500-bed flagship for the Cleveland Clinic Health System.

The Hospitalist spoke with Dr. Harte about SHM’s impact on his career and how he sees hospitalists’ roles growing in an evolving health system.

Question: In your speech at Hospital Medicine 2016 in San Diego, you referenced the critical need for hospitalists to explore opportunities to grow both personally and professionally, with SHM as a means of support. How has SHM been that support for you throughout your career from hospitalist to hospitalist leader?

Answer: Hospital medicine is a fantastic career because there are so many opportunities available to us. SHM supports our members in finding their own career paths in a number of ways. For example, Leadership Academy is a valuable resource to develop leadership skills from basic to advanced. More generally, SHM provides many role models and networking opportunities to allow others to learn from hospital medicine professionals and healthcare leaders and help them advance their careers.

Q: Tell us a bit about your expanded role at Cleveland Clinic Health System and how you can leverage SHM as a way to accomplish your goals in this new position.

A: I’ve been at Cleveland Clinic for 12 years, both as a hospitalist and in a number of leadership positions. After having served as president of Cleveland Clinic Hillcrest Hospital, I have a new role now as president of one of their newly acquired hospitals in Akron, Cleveland Clinic Akron General Hospital. Both are community hospitals within the Cleveland Clinic’s integrated healthcare network.

In my new role, I will be overseeing and facilitating the process of integration, and I’m really looking forward to it as a new challenge. I am particularly interested in how other health system and hospital executives who are hospitalists within SHM can help guide me and provide advice on how they have taken on challenges, built bridges, and overseen integration within other organizations.

Q: How does the career path of a hospitalist lend itself to leadership opportunities in a way that some other specialties may not?

A: Being a hospitalist lends itself to an almost limitless set of very interesting and rewarding career paths, both within and outside of pure clinical medicine. Hospitalists tend to have a very close relationship with administration, not just around clinical issues but around performance measurement and management. Because of this, we learn on the job about what leadership really consists of and that effective hospitalists are, by definition, effective leaders. What we do every day, functioning within and ultimately leading high-performing teams, epitomizes experiential leadership development.

SHM is positioned to help guide our members both in identifying their career paths and continuing to follow that path through events like Leadership Academy, Annual Meeting, and other networking opportunities that allow them to meet other hospitalists who have already walked down similar paths. We can help guide each other in terms of avoiding some of the pitfalls we have experienced but also by discovering opportunities and how to take advantage of them.

Q: Moving forward, how can hospitalists demonstrate the value that they add to the healthcare landscape both in practice and from a leadership perspective?

A: Since hospital medicine’s inception, hospitalists have had to show the value that they add to patient care, to hospitals, and to the healthcare system. As we move into an era of alternative payment models (APMs) and healthcare reform, the need to do that for all physicians will only be greater. Hospitalists are extremely well positioned to demonstrate value partly because we have been doing that all along in terms of improving patient care, quality outcomes, or performance measurements that the hospital is keeping track of.

We’re going to have to be stronger advocates for the value we provide to the healthcare system in terms of outcomes for patients as well as cost and efficiency. I know SHM will continue to help our members and the leaders within our membership develop the skills needed to do that.

Clinical Question: What is the validity of commonly held beliefs regarding serotonin syndrome (SS)?

Background: SS is a potentially life-threatening condition caused by serotonin excess in the central nervous system. The authors tested the validity of four widely accepted tenets about SS: that the Hunter criteria are superior, that the onset of SS is rapid compared to neuroleptic malignant syndrome (NMS), that hyperthermia is common with SS, and that SS can be distinguished from NMS based on medication history.

Study Design: Systematic review and meta-analysis.

Setting: PubMed and Web of Science.

Synopsis: Researchers identified 299 case reports from 2004 to 2014 in which SS was the most likely diagnosis based on one of three available diagnostic systems. Rhabdomyolysis with creatine kinase >1,500 and ICU treatment were used as proxies for SS severity. The Hunter criteria (the current gold standard) identified fewer overdoses, episodes of rhabdomyolysis, and ICU cases than the Sternbach or Radomski criteria. Combinations of antidepressants with methylene blue, opiates, or linezolid were the most common reasons for ICU admission. Symptom onset was within six hours in only 27.5% of cases. Hyperthermia was present in only 9.2% of patients with SS.

Hospitalists cannot rely on any one set of criteria to diagnose SS. The typical combinations of opiates or linezolid with antidepressants should raise the level of suspicion for SS. Rigidity and rhabdomyolysis occur commonly in both NMS and SS. Hyperthermia and timing of onset are not good indicators to the diagnosis of SS.

Bottom line: A high index of suspicion rather than reliance on classification systems or anecdotal key symptoms is necessary when considering SS.

Citation: Werneke U, Jamshidi F, Taylor DM, Ott M. Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases. BMC Neurol. 2016;16:97.

Clinical Question: What is the validity of commonly held beliefs regarding serotonin syndrome (SS)?

Background: SS is a potentially life-threatening condition caused by serotonin excess in the central nervous system. The authors tested the validity of four widely accepted tenets about SS: that the Hunter criteria are superior, that the onset of SS is rapid compared to neuroleptic malignant syndrome (NMS), that hyperthermia is common with SS, and that SS can be distinguished from NMS based on medication history.

Study Design: Systematic review and meta-analysis.

Setting: PubMed and Web of Science.

Synopsis: Researchers identified 299 case reports from 2004 to 2014 in which SS was the most likely diagnosis based on one of three available diagnostic systems. Rhabdomyolysis with creatine kinase >1,500 and ICU treatment were used as proxies for SS severity. The Hunter criteria (the current gold standard) identified fewer overdoses, episodes of rhabdomyolysis, and ICU cases than the Sternbach or Radomski criteria. Combinations of antidepressants with methylene blue, opiates, or linezolid were the most common reasons for ICU admission. Symptom onset was within six hours in only 27.5% of cases. Hyperthermia was present in only 9.2% of patients with SS.

Hospitalists cannot rely on any one set of criteria to diagnose SS. The typical combinations of opiates or linezolid with antidepressants should raise the level of suspicion for SS. Rigidity and rhabdomyolysis occur commonly in both NMS and SS. Hyperthermia and timing of onset are not good indicators to the diagnosis of SS.

Bottom line: A high index of suspicion rather than reliance on classification systems or anecdotal key symptoms is necessary when considering SS.

Citation: Werneke U, Jamshidi F, Taylor DM, Ott M. Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases. BMC Neurol. 2016;16:97.

Clinical Question: What is the validity of commonly held beliefs regarding serotonin syndrome (SS)?

Background: SS is a potentially life-threatening condition caused by serotonin excess in the central nervous system. The authors tested the validity of four widely accepted tenets about SS: that the Hunter criteria are superior, that the onset of SS is rapid compared to neuroleptic malignant syndrome (NMS), that hyperthermia is common with SS, and that SS can be distinguished from NMS based on medication history.

Study Design: Systematic review and meta-analysis.

Setting: PubMed and Web of Science.

Synopsis: Researchers identified 299 case reports from 2004 to 2014 in which SS was the most likely diagnosis based on one of three available diagnostic systems. Rhabdomyolysis with creatine kinase >1,500 and ICU treatment were used as proxies for SS severity. The Hunter criteria (the current gold standard) identified fewer overdoses, episodes of rhabdomyolysis, and ICU cases than the Sternbach or Radomski criteria. Combinations of antidepressants with methylene blue, opiates, or linezolid were the most common reasons for ICU admission. Symptom onset was within six hours in only 27.5% of cases. Hyperthermia was present in only 9.2% of patients with SS.

Hospitalists cannot rely on any one set of criteria to diagnose SS. The typical combinations of opiates or linezolid with antidepressants should raise the level of suspicion for SS. Rigidity and rhabdomyolysis occur commonly in both NMS and SS. Hyperthermia and timing of onset are not good indicators to the diagnosis of SS.

Bottom line: A high index of suspicion rather than reliance on classification systems or anecdotal key symptoms is necessary when considering SS.

Citation: Werneke U, Jamshidi F, Taylor DM, Ott M. Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases. BMC Neurol. 2016;16:97.

Clinical Question: Are there particular groups of patients in which lower transfusion thresholds (transfusion only at lower hemoglobin levels) may be harmful?

Background: Previously published meta-analyses have examined transfusion thresholds for critically ill, surgical, and medical patients. By combining these patients, previous meta-analyses are limited in the identification of intervention effects. A more refined understanding of how transfusion thresholds impact outcomes for a variety of patients in different clinical settings is needed.

Study Design: Context-specific systematic review and meta-analysis of randomized clinical trials.

Setting: Adult patients in perioperative, emergency, or intensive-care settings.

Synopsis: Patient information was extracted from 31 randomized clinical trials. The authors found that among 3,465 elderly patients undergoing orthopedic surgery, those given restrictive transfusion strategies had significantly more events reflecting inadequate oxygen supply (relative risk, 1.41; 95% CI, 1.03–1.92). No statistically significant effect from restrictive transfusions was seen in 3,322 patients with cardiovascular disease undergoing cardiac or vascular procedures; 3,590 mixed medical-surgical patients in emergency and intensive-care settings; and 823 patients in a combined group of postpartum women, hematologic malignancy patients, and younger patients with neurologic injury.

The authors argue that even statistically nonsignificant differences in morbidity and mortality should encourage more liberal transfusion; apart from orthopedic surgery patients, this argument is not well-supported by the available data.

Bottom Line: It remains unclear whether restrictive transfusion strategies have a negative impact on certain types of patients, although the authors argue that there may be a trend in that direction. Further study is needed for specific patient populations.

Citation: Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized clinical trials. Anesthesiology. 2016;125(1):46-61.

Clinical Question: Are there particular groups of patients in which lower transfusion thresholds (transfusion only at lower hemoglobin levels) may be harmful?

Background: Previously published meta-analyses have examined transfusion thresholds for critically ill, surgical, and medical patients. By combining these patients, previous meta-analyses are limited in the identification of intervention effects. A more refined understanding of how transfusion thresholds impact outcomes for a variety of patients in different clinical settings is needed.

Study Design: Context-specific systematic review and meta-analysis of randomized clinical trials.

Setting: Adult patients in perioperative, emergency, or intensive-care settings.

Synopsis: Patient information was extracted from 31 randomized clinical trials. The authors found that among 3,465 elderly patients undergoing orthopedic surgery, those given restrictive transfusion strategies had significantly more events reflecting inadequate oxygen supply (relative risk, 1.41; 95% CI, 1.03–1.92). No statistically significant effect from restrictive transfusions was seen in 3,322 patients with cardiovascular disease undergoing cardiac or vascular procedures; 3,590 mixed medical-surgical patients in emergency and intensive-care settings; and 823 patients in a combined group of postpartum women, hematologic malignancy patients, and younger patients with neurologic injury.

The authors argue that even statistically nonsignificant differences in morbidity and mortality should encourage more liberal transfusion; apart from orthopedic surgery patients, this argument is not well-supported by the available data.

Bottom Line: It remains unclear whether restrictive transfusion strategies have a negative impact on certain types of patients, although the authors argue that there may be a trend in that direction. Further study is needed for specific patient populations.

Citation: Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized clinical trials. Anesthesiology. 2016;125(1):46-61.

Clinical Question: Are there particular groups of patients in which lower transfusion thresholds (transfusion only at lower hemoglobin levels) may be harmful?

Background: Previously published meta-analyses have examined transfusion thresholds for critically ill, surgical, and medical patients. By combining these patients, previous meta-analyses are limited in the identification of intervention effects. A more refined understanding of how transfusion thresholds impact outcomes for a variety of patients in different clinical settings is needed.

Study Design: Context-specific systematic review and meta-analysis of randomized clinical trials.

Setting: Adult patients in perioperative, emergency, or intensive-care settings.

Synopsis: Patient information was extracted from 31 randomized clinical trials. The authors found that among 3,465 elderly patients undergoing orthopedic surgery, those given restrictive transfusion strategies had significantly more events reflecting inadequate oxygen supply (relative risk, 1.41; 95% CI, 1.03–1.92). No statistically significant effect from restrictive transfusions was seen in 3,322 patients with cardiovascular disease undergoing cardiac or vascular procedures; 3,590 mixed medical-surgical patients in emergency and intensive-care settings; and 823 patients in a combined group of postpartum women, hematologic malignancy patients, and younger patients with neurologic injury.

The authors argue that even statistically nonsignificant differences in morbidity and mortality should encourage more liberal transfusion; apart from orthopedic surgery patients, this argument is not well-supported by the available data.

Bottom Line: It remains unclear whether restrictive transfusion strategies have a negative impact on certain types of patients, although the authors argue that there may be a trend in that direction. Further study is needed for specific patient populations.

Citation: Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized clinical trials. Anesthesiology. 2016;125(1):46-61.

Metrics used by the Centers for Medicare & Medicaid Services to determine penalties for heart failure hospital readmissions are not associated with quality of care or overall clinical outcomes, according to data presented at the annual scientific sessions of the American Heart Association.

Ambarish Pandey, MD, of the University of Texas Southwestern Medical Center in Dallas, and his colleagues analyzed data from centers participating in the American Heart Association’s Get With The Guidelines-Heart Failure (GWTG-HF) registry linked to Medicare claims from July 2008 to June 2011. Centers were stratified as having low risk-adjusted readmission rates and high risk-adjusted readmission rates based on publicly available data from 2013.

The study included 171 centers with 43,143 patients. Centers were almost evenly split between low- and high-risk–adjusted 30-day readmission rates, with just a few more (51%) falling in the low-risk–adjusted category.

Performance was nearly equal (95.7% for centers with a low risk-adjusted readmission rate vs. 96.5% for those with high risk-adjusted rate) for median adherence to all performance measures, as was the case for median percentage of defect-free care (90.0% vs. 91.1%, respectively) and composite 1-year outcome of death or all-cause readmission rates (median 62.9% vs. 65.3%, respectively). The higher readmission group had higher 1-year all-cause readmission rates (median, 59.1% vs. 54.7%), Dr. Pandey and his colleagues reported in the study that was published simultaneously in JACC: Heart Failure (2016 Nov 15. doi. org/10.1016/j.jchf.2016). One-year mortality rates were lower in the higher readmission group with a trend toward statistical significance (median, 28.2% vs. 31.7%; P = 0.07).

Taken together, the findings suggest the 30-day readmission metrics currently used by CMS to determine readmission penalties are not associated with quality of care or overall clinical outcomes, Dr. Pandey and his colleagues wrote. Results showing higher 30-day readmissions do not necessarily reflect poor quality of care and may be related to other factors.

“These findings question the usefulness of the [hospital readmission reduction program] metric in identifying and penalizing hospitals with low quality of care,” Dr. Pandey wrote, adding that the findings were consistent with previous studies that have demonstrated a lack of association between in-hospital quality of care and 30-day readmission rates.

CMS implemented the federal Hospital Readmissions Reduction Program (HRRP) in 2012 to provide financial incentives for hospitals to reduce readmissions. Under the program, CMS uses claims data to determine whether readmission rates for heart failure, acute myocardial infarction, and pneumonia at eligible hospitals are higher than would be predicted by CMS models. Centers with higher than expected readmission rates face up to a 3% reimbursement penalty.

[email protected]

On Twitter @legal_med

Metrics used by the Centers for Medicare & Medicaid Services to determine penalties for heart failure hospital readmissions are not associated with quality of care or overall clinical outcomes, according to data presented at the annual scientific sessions of the American Heart Association.

Ambarish Pandey, MD, of the University of Texas Southwestern Medical Center in Dallas, and his colleagues analyzed data from centers participating in the American Heart Association’s Get With The Guidelines-Heart Failure (GWTG-HF) registry linked to Medicare claims from July 2008 to June 2011. Centers were stratified as having low risk-adjusted readmission rates and high risk-adjusted readmission rates based on publicly available data from 2013.

The study included 171 centers with 43,143 patients. Centers were almost evenly split between low- and high-risk–adjusted 30-day readmission rates, with just a few more (51%) falling in the low-risk–adjusted category.

Performance was nearly equal (95.7% for centers with a low risk-adjusted readmission rate vs. 96.5% for those with high risk-adjusted rate) for median adherence to all performance measures, as was the case for median percentage of defect-free care (90.0% vs. 91.1%, respectively) and composite 1-year outcome of death or all-cause readmission rates (median 62.9% vs. 65.3%, respectively). The higher readmission group had higher 1-year all-cause readmission rates (median, 59.1% vs. 54.7%), Dr. Pandey and his colleagues reported in the study that was published simultaneously in JACC: Heart Failure (2016 Nov 15. doi. org/10.1016/j.jchf.2016). One-year mortality rates were lower in the higher readmission group with a trend toward statistical significance (median, 28.2% vs. 31.7%; P = 0.07).

Taken together, the findings suggest the 30-day readmission metrics currently used by CMS to determine readmission penalties are not associated with quality of care or overall clinical outcomes, Dr. Pandey and his colleagues wrote. Results showing higher 30-day readmissions do not necessarily reflect poor quality of care and may be related to other factors.

“These findings question the usefulness of the [hospital readmission reduction program] metric in identifying and penalizing hospitals with low quality of care,” Dr. Pandey wrote, adding that the findings were consistent with previous studies that have demonstrated a lack of association between in-hospital quality of care and 30-day readmission rates.

CMS implemented the federal Hospital Readmissions Reduction Program (HRRP) in 2012 to provide financial incentives for hospitals to reduce readmissions. Under the program, CMS uses claims data to determine whether readmission rates for heart failure, acute myocardial infarction, and pneumonia at eligible hospitals are higher than would be predicted by CMS models. Centers with higher than expected readmission rates face up to a 3% reimbursement penalty.

[email protected]

On Twitter @legal_med

Metrics used by the Centers for Medicare & Medicaid Services to determine penalties for heart failure hospital readmissions are not associated with quality of care or overall clinical outcomes, according to data presented at the annual scientific sessions of the American Heart Association.

Ambarish Pandey, MD, of the University of Texas Southwestern Medical Center in Dallas, and his colleagues analyzed data from centers participating in the American Heart Association’s Get With The Guidelines-Heart Failure (GWTG-HF) registry linked to Medicare claims from July 2008 to June 2011. Centers were stratified as having low risk-adjusted readmission rates and high risk-adjusted readmission rates based on publicly available data from 2013.

The study included 171 centers with 43,143 patients. Centers were almost evenly split between low- and high-risk–adjusted 30-day readmission rates, with just a few more (51%) falling in the low-risk–adjusted category.

Performance was nearly equal (95.7% for centers with a low risk-adjusted readmission rate vs. 96.5% for those with high risk-adjusted rate) for median adherence to all performance measures, as was the case for median percentage of defect-free care (90.0% vs. 91.1%, respectively) and composite 1-year outcome of death or all-cause readmission rates (median 62.9% vs. 65.3%, respectively). The higher readmission group had higher 1-year all-cause readmission rates (median, 59.1% vs. 54.7%), Dr. Pandey and his colleagues reported in the study that was published simultaneously in JACC: Heart Failure (2016 Nov 15. doi. org/10.1016/j.jchf.2016). One-year mortality rates were lower in the higher readmission group with a trend toward statistical significance (median, 28.2% vs. 31.7%; P = 0.07).

Taken together, the findings suggest the 30-day readmission metrics currently used by CMS to determine readmission penalties are not associated with quality of care or overall clinical outcomes, Dr. Pandey and his colleagues wrote. Results showing higher 30-day readmissions do not necessarily reflect poor quality of care and may be related to other factors.

“These findings question the usefulness of the [hospital readmission reduction program] metric in identifying and penalizing hospitals with low quality of care,” Dr. Pandey wrote, adding that the findings were consistent with previous studies that have demonstrated a lack of association between in-hospital quality of care and 30-day readmission rates.

CMS implemented the federal Hospital Readmissions Reduction Program (HRRP) in 2012 to provide financial incentives for hospitals to reduce readmissions. Under the program, CMS uses claims data to determine whether readmission rates for heart failure, acute myocardial infarction, and pneumonia at eligible hospitals are higher than would be predicted by CMS models. Centers with higher than expected readmission rates face up to a 3% reimbursement penalty.

[email protected]

On Twitter @legal_med

Editor’s note: As SHM celebrates the “Year of the Hospitalist,” we’re putting the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/yoth for more information on how you can join the yearlong celebration and help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Moises Auron, MD, SFHM, a dual internal medicine/pediatrics hospitalist at the Cleveland Clinic. He is board certified in internal medicine and pediatrics and serves as associate professor of medicine and pediatrics at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: I joined SHM as a third-year med-peds resident, influenced by my mentor and teacher, Dr. James C. Pile. I completed my medicine and perioperative consult rotation with him, and it was the first time in ages that anybody had served as such a motivating role model. He gave me a collection of The Hospitalist newsmagazines focused on perioperative medicine as well as a pack of articles around pertinent subjects for an internal medicine consultation service. It was a breath of fresh air; I found an entirely new niche in medicine. And in addition, he demonstrated to me how being a hospitalist was a fundamental pillar of patient care within the healthcare system. He showed me the elements of a thorough and pertinent system-based practice.

I met SHM CEO Dr. Larry Wellikson and the SHM team during a meeting in Philadelphia about 10 years ago and became even more acquainted with the society and its goals. I became a member on the spot. As a resident, I loved receiving both The Hospitalist and the Journal of Hospital Medicine. Both helped me also in my initial job search during my senior year of residency as well as with familiarizing myself with the latest hospital medicine literature. In short, being a member of SHM helped me cement my professional career path to hospital medicine.

Q: How has SHM provided you with resources to improve patient care and further your career?

I had the privilege of attending the Academic Hospitalist Academy and the Quality and Safety Educators Academy as well; both have helped me foster further goals in my career as well as achieve substantial professional and personal satisfaction.

The most important aspect of my membership has been becoming acquainted with a tremendous group of talented human beings, including both the SHM staff as well as hospitalist colleagues. The strength of SHM is its people: passionate providers and administrators who aim to make a better world for patients and doctors.

Q: What is your proudest moment working in hospital medicine?

A: Every single day of my job. As an academic hospitalist and a quality officer at my institution, I take tremendous pride in my job. I define ourselves as the super-internists; we are a quaternary medical center that cares for patients referred from all over the nation, and we need to elucidate obscure diagnoses and aim to offer a treatment and hope.

To me, what is more important is when I witness my residents being actively mindful about preventing harm: when they hardwire best practices such as good hand hygiene, precautions for prevention of falls, risk mitigation associated with any medical intervention … The list goes on. When I appreciate that behavior that becomes my proudest moment because I know that they will ensure the best outcomes for our patients and that I have made an impact.

Q: What do you see as the biggest opportunity for hospitalists as healthcare continues to evolve, and how can hospitalists rise to the challenge?

A: As the saying goes, “One of the tests of leadership is the ability to recognize a problem before it becomes an emergency.” We need to anticipate the way American healthcare is being delivered. The business model is changing, and the payment system is transitioning. Quality is being leveraged as a tool to decrease costs of care.

Hospitalists need to be creative in capitalizing on each individual patient encounter to maximize communication with other members of the healthcare team and use the patient’s hospitalization time strategically. We need to be the savings experts. We can recognize areas where unnecessary expenditure is used by having a lean mind and focusing on removing waste that will not impact our patients. We are the experts on the front line—we need to share the feedback to the leadership.

Q: What advice would you give to future providers considering a career in hospital medicine?

A: Become an SHM member early in your residency, aim to present a poster, participate at an SHM meeting, and engage in the networking process. SHM offers educational initiatives (e.g., Leadership Academy, Academic Hospitalist Academy, Quality and Safety Educators Academy), quality improvement programs (e.g., BOOST and Glycemic Control), and educational content to ensure your success in the Focused Practice in Hospital Medicine exam via the SHM SPARK tool.

Why so early? Because all of these resources help to build a sense of purpose and help to answer the question, “Where do I want to be five years from now?” Networking is fundamental, especially as it gives the opportunity to develop potential mentorship relationships and create teams for future collaboration endeavors.

Editor’s note: As SHM celebrates the “Year of the Hospitalist,” we’re putting the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/yoth for more information on how you can join the yearlong celebration and help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Moises Auron, MD, SFHM, a dual internal medicine/pediatrics hospitalist at the Cleveland Clinic. He is board certified in internal medicine and pediatrics and serves as associate professor of medicine and pediatrics at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: I joined SHM as a third-year med-peds resident, influenced by my mentor and teacher, Dr. James C. Pile. I completed my medicine and perioperative consult rotation with him, and it was the first time in ages that anybody had served as such a motivating role model. He gave me a collection of The Hospitalist newsmagazines focused on perioperative medicine as well as a pack of articles around pertinent subjects for an internal medicine consultation service. It was a breath of fresh air; I found an entirely new niche in medicine. And in addition, he demonstrated to me how being a hospitalist was a fundamental pillar of patient care within the healthcare system. He showed me the elements of a thorough and pertinent system-based practice.

I met SHM CEO Dr. Larry Wellikson and the SHM team during a meeting in Philadelphia about 10 years ago and became even more acquainted with the society and its goals. I became a member on the spot. As a resident, I loved receiving both The Hospitalist and the Journal of Hospital Medicine. Both helped me also in my initial job search during my senior year of residency as well as with familiarizing myself with the latest hospital medicine literature. In short, being a member of SHM helped me cement my professional career path to hospital medicine.

Q: How has SHM provided you with resources to improve patient care and further your career?

I had the privilege of attending the Academic Hospitalist Academy and the Quality and Safety Educators Academy as well; both have helped me foster further goals in my career as well as achieve substantial professional and personal satisfaction.

The most important aspect of my membership has been becoming acquainted with a tremendous group of talented human beings, including both the SHM staff as well as hospitalist colleagues. The strength of SHM is its people: passionate providers and administrators who aim to make a better world for patients and doctors.

Q: What is your proudest moment working in hospital medicine?

A: Every single day of my job. As an academic hospitalist and a quality officer at my institution, I take tremendous pride in my job. I define ourselves as the super-internists; we are a quaternary medical center that cares for patients referred from all over the nation, and we need to elucidate obscure diagnoses and aim to offer a treatment and hope.

To me, what is more important is when I witness my residents being actively mindful about preventing harm: when they hardwire best practices such as good hand hygiene, precautions for prevention of falls, risk mitigation associated with any medical intervention … The list goes on. When I appreciate that behavior that becomes my proudest moment because I know that they will ensure the best outcomes for our patients and that I have made an impact.

Q: What do you see as the biggest opportunity for hospitalists as healthcare continues to evolve, and how can hospitalists rise to the challenge?

A: As the saying goes, “One of the tests of leadership is the ability to recognize a problem before it becomes an emergency.” We need to anticipate the way American healthcare is being delivered. The business model is changing, and the payment system is transitioning. Quality is being leveraged as a tool to decrease costs of care.

Hospitalists need to be creative in capitalizing on each individual patient encounter to maximize communication with other members of the healthcare team and use the patient’s hospitalization time strategically. We need to be the savings experts. We can recognize areas where unnecessary expenditure is used by having a lean mind and focusing on removing waste that will not impact our patients. We are the experts on the front line—we need to share the feedback to the leadership.

Q: What advice would you give to future providers considering a career in hospital medicine?

A: Become an SHM member early in your residency, aim to present a poster, participate at an SHM meeting, and engage in the networking process. SHM offers educational initiatives (e.g., Leadership Academy, Academic Hospitalist Academy, Quality and Safety Educators Academy), quality improvement programs (e.g., BOOST and Glycemic Control), and educational content to ensure your success in the Focused Practice in Hospital Medicine exam via the SHM SPARK tool.

Why so early? Because all of these resources help to build a sense of purpose and help to answer the question, “Where do I want to be five years from now?” Networking is fundamental, especially as it gives the opportunity to develop potential mentorship relationships and create teams for future collaboration endeavors.

Editor’s note: As SHM celebrates the “Year of the Hospitalist,” we’re putting the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/yoth for more information on how you can join the yearlong celebration and help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Moises Auron, MD, SFHM, a dual internal medicine/pediatrics hospitalist at the Cleveland Clinic. He is board certified in internal medicine and pediatrics and serves as associate professor of medicine and pediatrics at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: I joined SHM as a third-year med-peds resident, influenced by my mentor and teacher, Dr. James C. Pile. I completed my medicine and perioperative consult rotation with him, and it was the first time in ages that anybody had served as such a motivating role model. He gave me a collection of The Hospitalist newsmagazines focused on perioperative medicine as well as a pack of articles around pertinent subjects for an internal medicine consultation service. It was a breath of fresh air; I found an entirely new niche in medicine. And in addition, he demonstrated to me how being a hospitalist was a fundamental pillar of patient care within the healthcare system. He showed me the elements of a thorough and pertinent system-based practice.

I met SHM CEO Dr. Larry Wellikson and the SHM team during a meeting in Philadelphia about 10 years ago and became even more acquainted with the society and its goals. I became a member on the spot. As a resident, I loved receiving both The Hospitalist and the Journal of Hospital Medicine. Both helped me also in my initial job search during my senior year of residency as well as with familiarizing myself with the latest hospital medicine literature. In short, being a member of SHM helped me cement my professional career path to hospital medicine.

Q: How has SHM provided you with resources to improve patient care and further your career?

I had the privilege of attending the Academic Hospitalist Academy and the Quality and Safety Educators Academy as well; both have helped me foster further goals in my career as well as achieve substantial professional and personal satisfaction.

The most important aspect of my membership has been becoming acquainted with a tremendous group of talented human beings, including both the SHM staff as well as hospitalist colleagues. The strength of SHM is its people: passionate providers and administrators who aim to make a better world for patients and doctors.

Q: What is your proudest moment working in hospital medicine?

A: Every single day of my job. As an academic hospitalist and a quality officer at my institution, I take tremendous pride in my job. I define ourselves as the super-internists; we are a quaternary medical center that cares for patients referred from all over the nation, and we need to elucidate obscure diagnoses and aim to offer a treatment and hope.

To me, what is more important is when I witness my residents being actively mindful about preventing harm: when they hardwire best practices such as good hand hygiene, precautions for prevention of falls, risk mitigation associated with any medical intervention … The list goes on. When I appreciate that behavior that becomes my proudest moment because I know that they will ensure the best outcomes for our patients and that I have made an impact.

Q: What do you see as the biggest opportunity for hospitalists as healthcare continues to evolve, and how can hospitalists rise to the challenge?

A: As the saying goes, “One of the tests of leadership is the ability to recognize a problem before it becomes an emergency.” We need to anticipate the way American healthcare is being delivered. The business model is changing, and the payment system is transitioning. Quality is being leveraged as a tool to decrease costs of care.

Hospitalists need to be creative in capitalizing on each individual patient encounter to maximize communication with other members of the healthcare team and use the patient’s hospitalization time strategically. We need to be the savings experts. We can recognize areas where unnecessary expenditure is used by having a lean mind and focusing on removing waste that will not impact our patients. We are the experts on the front line—we need to share the feedback to the leadership.

Q: What advice would you give to future providers considering a career in hospital medicine?

A: Become an SHM member early in your residency, aim to present a poster, participate at an SHM meeting, and engage in the networking process. SHM offers educational initiatives (e.g., Leadership Academy, Academic Hospitalist Academy, Quality and Safety Educators Academy), quality improvement programs (e.g., BOOST and Glycemic Control), and educational content to ensure your success in the Focused Practice in Hospital Medicine exam via the SHM SPARK tool.

Why so early? Because all of these resources help to build a sense of purpose and help to answer the question, “Where do I want to be five years from now?” Networking is fundamental, especially as it gives the opportunity to develop potential mentorship relationships and create teams for future collaboration endeavors.

Choosing hospital medicine as a specialty means choosing between practicing community HM or academic HM. Or does it? Elizabeth Cook, MD, of Hospital Medicine Associates in Lynchburg VA; Stella Fitzgibbon, MD, FACP, FHM, with Memorial Hermann Hospital in The Woodlands, TX; and Chris Moriates, MD, of Dell Medical School at UT Austin, talk about the options available in community and academic HM, and moving between them during an HM career.

Choosing hospital medicine as a specialty means choosing between practicing community HM or academic HM. Or does it? Elizabeth Cook, MD, of Hospital Medicine Associates in Lynchburg VA; Stella Fitzgibbon, MD, FACP, FHM, with Memorial Hermann Hospital in The Woodlands, TX; and Chris Moriates, MD, of Dell Medical School at UT Austin, talk about the options available in community and academic HM, and moving between them during an HM career.

Choosing hospital medicine as a specialty means choosing between practicing community HM or academic HM. Or does it? Elizabeth Cook, MD, of Hospital Medicine Associates in Lynchburg VA; Stella Fitzgibbon, MD, FACP, FHM, with Memorial Hermann Hospital in The Woodlands, TX; and Chris Moriates, MD, of Dell Medical School at UT Austin, talk about the options available in community and academic HM, and moving between them during an HM career.

WASHINGTON – Patients with traumatic injuries don’t appear to be at undue risk of sustained opioid use, a large database review has demonstrated.

More than half of the 13,000 patients in the study were discharged on opioids, but they were able to discontinue them fairly rapidly, Muhammad Chaudhary, MD, said at the annual clinical congress of the American College of Surgeons. Within 3 months, less than one-third were still using the drugs, and 1 year later, only 1% were still taking an opioid pain medication.

[email protected]

On Twitter @alz_gal

WASHINGTON – Patients with traumatic injuries don’t appear to be at undue risk of sustained opioid use, a large database review has demonstrated.

More than half of the 13,000 patients in the study were discharged on opioids, but they were able to discontinue them fairly rapidly, Muhammad Chaudhary, MD, said at the annual clinical congress of the American College of Surgeons. Within 3 months, less than one-third were still using the drugs, and 1 year later, only 1% were still taking an opioid pain medication.

[email protected]

On Twitter @alz_gal

WASHINGTON – Patients with traumatic injuries don’t appear to be at undue risk of sustained opioid use, a large database review has demonstrated.

More than half of the 13,000 patients in the study were discharged on opioids, but they were able to discontinue them fairly rapidly, Muhammad Chaudhary, MD, said at the annual clinical congress of the American College of Surgeons. Within 3 months, less than one-third were still using the drugs, and 1 year later, only 1% were still taking an opioid pain medication.

[email protected]

On Twitter @alz_gal

Clinical Question: What is the incidence of loss of independence (LOI) for older adults after surgery, and is there an association between LOI and readmission or death?

Background: LOI is being increasingly recognized as an important measure of patient-centered care and a potential opportunity for intervention to prevent disablement. This study is the first to examine links between LOI and rates of readmission or death following surgery.

Study Design: Retrospective cohort.

Setting: 26 U.S. hospitals participating in a national quality improvement project.

Synopsis: The authors examined data from 5,077 patients age 65 or older undergoing an inpatient surgical procedure. They examined ability to perform activities of daily living (ADLs), mobility, and living situation before and after surgery, and they defined LOI as a change in one or more of these factors at the time of discharge.

They found that LOI increased with age, with 49.9% of patients ages 65–74, 67.3% of patients ages 75–84, and 83.9% of patients age 85 or older experiencing LOI. The study also showed an association between LOI and negative outcomes, including readmission (odds ratio, 1.7) and death after discharge (odds ratio, 6.7).

Although this study was retrospective, the findings indicate that LOI is strongly correlated with negative short-term outcomes, especially in older populations. LOI related to surgery is a measure that deserves closer attention and greater future study as a potential target for clinical initiatives and intervention.

Bottom Line: LOI (functional ability, mobility, and living situation) after surgery increases with age and is associated with negative short-term outcomes including readmission and death.

Citation: Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.

Short Take

Transition to New Electronic Health Records Systems Does Not Increase Adverse Outcomes

An observational study comparing 17 hospitals implementing new electronic health records systems with 399 control hospitals showed no difference in the rate of adverse safety events or readmissions following implementation.

Citation: Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ. 2016;354:i3835.

Clinical Question: What is the incidence of loss of independence (LOI) for older adults after surgery, and is there an association between LOI and readmission or death?

Background: LOI is being increasingly recognized as an important measure of patient-centered care and a potential opportunity for intervention to prevent disablement. This study is the first to examine links between LOI and rates of readmission or death following surgery.

Study Design: Retrospective cohort.

Setting: 26 U.S. hospitals participating in a national quality improvement project.

Synopsis: The authors examined data from 5,077 patients age 65 or older undergoing an inpatient surgical procedure. They examined ability to perform activities of daily living (ADLs), mobility, and living situation before and after surgery, and they defined LOI as a change in one or more of these factors at the time of discharge.

They found that LOI increased with age, with 49.9% of patients ages 65–74, 67.3% of patients ages 75–84, and 83.9% of patients age 85 or older experiencing LOI. The study also showed an association between LOI and negative outcomes, including readmission (odds ratio, 1.7) and death after discharge (odds ratio, 6.7).

Although this study was retrospective, the findings indicate that LOI is strongly correlated with negative short-term outcomes, especially in older populations. LOI related to surgery is a measure that deserves closer attention and greater future study as a potential target for clinical initiatives and intervention.

Bottom Line: LOI (functional ability, mobility, and living situation) after surgery increases with age and is associated with negative short-term outcomes including readmission and death.

Citation: Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.

Short Take

Transition to New Electronic Health Records Systems Does Not Increase Adverse Outcomes

An observational study comparing 17 hospitals implementing new electronic health records systems with 399 control hospitals showed no difference in the rate of adverse safety events or readmissions following implementation.

Citation: Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ. 2016;354:i3835.

Clinical Question: What is the incidence of loss of independence (LOI) for older adults after surgery, and is there an association between LOI and readmission or death?

Background: LOI is being increasingly recognized as an important measure of patient-centered care and a potential opportunity for intervention to prevent disablement. This study is the first to examine links between LOI and rates of readmission or death following surgery.

Study Design: Retrospective cohort.

Setting: 26 U.S. hospitals participating in a national quality improvement project.

Synopsis: The authors examined data from 5,077 patients age 65 or older undergoing an inpatient surgical procedure. They examined ability to perform activities of daily living (ADLs), mobility, and living situation before and after surgery, and they defined LOI as a change in one or more of these factors at the time of discharge.

They found that LOI increased with age, with 49.9% of patients ages 65–74, 67.3% of patients ages 75–84, and 83.9% of patients age 85 or older experiencing LOI. The study also showed an association between LOI and negative outcomes, including readmission (odds ratio, 1.7) and death after discharge (odds ratio, 6.7).

Although this study was retrospective, the findings indicate that LOI is strongly correlated with negative short-term outcomes, especially in older populations. LOI related to surgery is a measure that deserves closer attention and greater future study as a potential target for clinical initiatives and intervention.

Bottom Line: LOI (functional ability, mobility, and living situation) after surgery increases with age and is associated with negative short-term outcomes including readmission and death.

Citation: Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.

Short Take

Transition to New Electronic Health Records Systems Does Not Increase Adverse Outcomes

An observational study comparing 17 hospitals implementing new electronic health records systems with 399 control hospitals showed no difference in the rate of adverse safety events or readmissions following implementation.

Citation: Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ. 2016;354:i3835.

Clinical Question: What data are available regarding the attitudes toward and the practice of euthanasia and physician-assisted suicide (PAS)?

Background: Although controversial, euthanasia and PAS are currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada, while PAS (but not euthanasia) is legal in Switzerland and five states (Oregon, Washington, Montana, Vermont, and California). Knowledge about current practices is limited as only a portion of these jurisdictions have reporting requirements.

Study Design: Literature review with a focus on original data.

Setting: Data from United States, Canada, and Europe.

Synopsis: Published data from 1947 to 2016 were reviewed. U.S. public opinion surveys show a recent decline in support of PAS, from a peak of 75% in 2005 to 64% in 2012. With the exception of the Netherlands and Belgium, physicians in the U.S., Europe, and Australia are less supportive than the general public.

In the U.S., <20% of physicians reported receiving a request for euthanasia or PAS, and <5% complied. Oncologists are most likely to receive a patient request. The typical patient is older, white, insured, well-educated, and enrolled in hospice. Seventy-five percent have cancer, while 15% have neurodegenerative conditions. Loss of autonomy and dignity are common motivators, while <33% of patients cite uncontrolled pain. PAS remains rare, accounting for <0.4% of all deaths. Existing data do not indicate abuse of these practices.

The authors emphasize that existing data are limited and recommend that all countries, not just those where euthanasia and/or PAS are legal, should formally collect information on end-of-life practices.

Bottom Line: Euthanasia and PAS remain relatively rare and primarily involve oncology patients despite increasing legalization.

Citation: Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.

Short Take

Peer Support for Physicians May Curb Burnout

This perspective piece outlines a program of one-to-one peer outreach for physicians as a way to mitigate stress especially when dealing with adverse events or litigation, but no data are provided.

Citation: Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.

Clinical Question: What data are available regarding the attitudes toward and the practice of euthanasia and physician-assisted suicide (PAS)?

Background: Although controversial, euthanasia and PAS are currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada, while PAS (but not euthanasia) is legal in Switzerland and five states (Oregon, Washington, Montana, Vermont, and California). Knowledge about current practices is limited as only a portion of these jurisdictions have reporting requirements.

Study Design: Literature review with a focus on original data.

Setting: Data from United States, Canada, and Europe.

Synopsis: Published data from 1947 to 2016 were reviewed. U.S. public opinion surveys show a recent decline in support of PAS, from a peak of 75% in 2005 to 64% in 2012. With the exception of the Netherlands and Belgium, physicians in the U.S., Europe, and Australia are less supportive than the general public.

In the U.S., <20% of physicians reported receiving a request for euthanasia or PAS, and <5% complied. Oncologists are most likely to receive a patient request. The typical patient is older, white, insured, well-educated, and enrolled in hospice. Seventy-five percent have cancer, while 15% have neurodegenerative conditions. Loss of autonomy and dignity are common motivators, while <33% of patients cite uncontrolled pain. PAS remains rare, accounting for <0.4% of all deaths. Existing data do not indicate abuse of these practices.

The authors emphasize that existing data are limited and recommend that all countries, not just those where euthanasia and/or PAS are legal, should formally collect information on end-of-life practices.

Bottom Line: Euthanasia and PAS remain relatively rare and primarily involve oncology patients despite increasing legalization.

Citation: Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.

Short Take

Peer Support for Physicians May Curb Burnout

This perspective piece outlines a program of one-to-one peer outreach for physicians as a way to mitigate stress especially when dealing with adverse events or litigation, but no data are provided.

Citation: Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.

Clinical Question: What data are available regarding the attitudes toward and the practice of euthanasia and physician-assisted suicide (PAS)?

Background: Although controversial, euthanasia and PAS are currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada, while PAS (but not euthanasia) is legal in Switzerland and five states (Oregon, Washington, Montana, Vermont, and California). Knowledge about current practices is limited as only a portion of these jurisdictions have reporting requirements.

Study Design: Literature review with a focus on original data.

Setting: Data from United States, Canada, and Europe.

Synopsis: Published data from 1947 to 2016 were reviewed. U.S. public opinion surveys show a recent decline in support of PAS, from a peak of 75% in 2005 to 64% in 2012. With the exception of the Netherlands and Belgium, physicians in the U.S., Europe, and Australia are less supportive than the general public.

In the U.S., <20% of physicians reported receiving a request for euthanasia or PAS, and <5% complied. Oncologists are most likely to receive a patient request. The typical patient is older, white, insured, well-educated, and enrolled in hospice. Seventy-five percent have cancer, while 15% have neurodegenerative conditions. Loss of autonomy and dignity are common motivators, while <33% of patients cite uncontrolled pain. PAS remains rare, accounting for <0.4% of all deaths. Existing data do not indicate abuse of these practices.

The authors emphasize that existing data are limited and recommend that all countries, not just those where euthanasia and/or PAS are legal, should formally collect information on end-of-life practices.

Bottom Line: Euthanasia and PAS remain relatively rare and primarily involve oncology patients despite increasing legalization.

Citation: Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.

Short Take

Peer Support for Physicians May Curb Burnout

This perspective piece outlines a program of one-to-one peer outreach for physicians as a way to mitigate stress especially when dealing with adverse events or litigation, but no data are provided.

Citation: Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.