The Hospitalist

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

The hospitalist’s performance is among the major determinants of a patient’s hospital experience. But what are the elements of a successful interaction? The authors of an article published in the Journal of Hospital Medicine set out to establish metrics to answer—and measure the answer—to that question, to assess hospitalists’ behaviors, and to establish norms and expectations.

“This study represents a first step to specifically characterize comportment and communication in hospital medicine,” the authors write.

Patient satisfaction surveys, they state, have some shortcomings in providing useful answers to that question.

“First, the attribution to specific providers is questionable,” the authors write. “Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time.”

Researchers asked the chiefs of hospital medicine divisions at five hospitals to identify their “most clinically excellent” hospitalists. Each hospitalist was observed during a routine clinical shift, and behaviors were recorded that were believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT), the final version of which has 23 variables. The physicians’ HMCCOT scores were associated with their patient satisfaction survey scores, suggesting that improved comportment might translate into enhanced patient satisfaction.

The results showed extensive variability in comportment and communication at the bedside. One variable that stood out to the researchers was that teach-back was employed in only 13% of the encounters.

“Previous studies have shown that teach-back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization,” the researchers write. “Further, patients who clearly understand their post-discharge plan are 30% less likely to be readmitted or visit the emergency department. The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States, as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.”

The researchers call for future studies to determine whether hospitalists can improve feedback from this tool and whether enhancing comportment and communication can improve both patient satisfaction and clinical outcomes.

Reference

1. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine [published online ahead of print August 13, 2016]. J Hosp Med. doi:10.1002/jhm.2647.

The hospitalist’s performance is among the major determinants of a patient’s hospital experience. But what are the elements of a successful interaction? The authors of an article published in the Journal of Hospital Medicine set out to establish metrics to answer—and measure the answer—to that question, to assess hospitalists’ behaviors, and to establish norms and expectations.

“This study represents a first step to specifically characterize comportment and communication in hospital medicine,” the authors write.

Patient satisfaction surveys, they state, have some shortcomings in providing useful answers to that question.

“First, the attribution to specific providers is questionable,” the authors write. “Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time.”

Researchers asked the chiefs of hospital medicine divisions at five hospitals to identify their “most clinically excellent” hospitalists. Each hospitalist was observed during a routine clinical shift, and behaviors were recorded that were believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT), the final version of which has 23 variables. The physicians’ HMCCOT scores were associated with their patient satisfaction survey scores, suggesting that improved comportment might translate into enhanced patient satisfaction.

The results showed extensive variability in comportment and communication at the bedside. One variable that stood out to the researchers was that teach-back was employed in only 13% of the encounters.

“Previous studies have shown that teach-back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization,” the researchers write. “Further, patients who clearly understand their post-discharge plan are 30% less likely to be readmitted or visit the emergency department. The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States, as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.”

The researchers call for future studies to determine whether hospitalists can improve feedback from this tool and whether enhancing comportment and communication can improve both patient satisfaction and clinical outcomes.

Reference

1. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine [published online ahead of print August 13, 2016]. J Hosp Med. doi:10.1002/jhm.2647.

The hospitalist’s performance is among the major determinants of a patient’s hospital experience. But what are the elements of a successful interaction? The authors of an article published in the Journal of Hospital Medicine set out to establish metrics to answer—and measure the answer—to that question, to assess hospitalists’ behaviors, and to establish norms and expectations.

“This study represents a first step to specifically characterize comportment and communication in hospital medicine,” the authors write.

Patient satisfaction surveys, they state, have some shortcomings in providing useful answers to that question.

“First, the attribution to specific providers is questionable,” the authors write. “Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time.”

Researchers asked the chiefs of hospital medicine divisions at five hospitals to identify their “most clinically excellent” hospitalists. Each hospitalist was observed during a routine clinical shift, and behaviors were recorded that were believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT), the final version of which has 23 variables. The physicians’ HMCCOT scores were associated with their patient satisfaction survey scores, suggesting that improved comportment might translate into enhanced patient satisfaction.

The results showed extensive variability in comportment and communication at the bedside. One variable that stood out to the researchers was that teach-back was employed in only 13% of the encounters.

“Previous studies have shown that teach-back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization,” the researchers write. “Further, patients who clearly understand their post-discharge plan are 30% less likely to be readmitted or visit the emergency department. The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States, as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.”

The researchers call for future studies to determine whether hospitalists can improve feedback from this tool and whether enhancing comportment and communication can improve both patient satisfaction and clinical outcomes.

Reference

1. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine [published online ahead of print August 13, 2016]. J Hosp Med. doi:10.1002/jhm.2647.

Dear Dr. Hospitalist:

I completed my residency approximately a year ago and was hired by a large academic hospital medicine program with an H-1B visa. After six to eight months in what I thought was the “application process” for permanent residency, I discovered that the people responsible for filing the necessary paperwork had not done anything. During this delayed application period, it is too risky to travel internationally. While I’m still gracious for the opportunity to train and work in the U.S., I am depressed and angry because I haven’t seen my family for almost two years. Should I escalate and complain about my situation beyond the director of my division or just sit back and wait it out?

Dr. Angry and in Limbo

Dr. Hospitalist responds:

There were 2,576 H-1B petitions approved for physicians and surgeons in FY 2012.1 Even though the Society of Hospital Medicine does not currently track the number of international medical graduates (IMGs) in the U.S. practicing hospital medicine, most authorities believe it’s between 20 and 25 percent of the current workforce. 2 Undoubtedly, many of these docs are already U.S. citizens, but most work in the U.S. on employer-sponsored programs (H1-B), with a few taking the J-1 visa tract. Both programs are often used as a catalyst to permanent residency, but the J-1 requires the individual to work in an underserved area for three years before being eligible.

Because the H-1B visa individual can only maintain this status for three years at a time for a maximum of six years, I’m assuming you used three years of the program to complete your residency and will either need to obtain permanent residency (a green card) very soon or will have to leave the country for at least a year before you can apply again. The law does grant extensions beyond this six-year period but only when certain parts of the green card process have been pending for one year prior to the requested H1-B start date.

Assuming you have no culpability for the delay in processing the application (e.g., you turned in necessary paperwork on time, responded timely to correspondence from processors), you have every right to be angry. The application process is tedious and very complex, with very rigid time constraints. Many organizations have used physicians with H-1B visas to fill the gaps in their recruiting without the necessary infrastructure to support the needs of this group. While I recognize it would be difficult for small groups or hospitals to afford knowledgeable and skilled support staff, the days of having part-time administrative support to manage this task are long gone. There are web-based organizations that are skilled and affordable for the smaller groups, and larger groups should invest in administrative staff to support their physicians with visas. After all, in this era of “we’re all part of the team,” it’s difficult to feel valued when your ability to borrow money or travel internationally is limited or even worse: You could be deported.

As an ex-military guy, following the chain of command is in my blood. However, if after given reasonable opportunity to assist and rectify your issues, the division director is unresponsive or unable to assist, I would escalate to the department chair and beyond if necessary.

Good luck! TH

References

1. U.S. Department of Homeland Security, U.S. Citizenship and Immigration Services. Characteristics of H1B Specialty Occupation Workers: Fiscal Year 21012 Annual Report to Congress. U.S. Citizenship and Immigration Services website. Accessed October 17, 2016
2. Educational Commission for Foreign Medical Graduates [10-06-2012];Annual Report.

   Accessed October 17, 2016

Dear Dr. Hospitalist:

I completed my residency approximately a year ago and was hired by a large academic hospital medicine program with an H-1B visa. After six to eight months in what I thought was the “application process” for permanent residency, I discovered that the people responsible for filing the necessary paperwork had not done anything. During this delayed application period, it is too risky to travel internationally. While I’m still gracious for the opportunity to train and work in the U.S., I am depressed and angry because I haven’t seen my family for almost two years. Should I escalate and complain about my situation beyond the director of my division or just sit back and wait it out?

Dr. Angry and in Limbo

Dr. Hospitalist responds:

There were 2,576 H-1B petitions approved for physicians and surgeons in FY 2012.1 Even though the Society of Hospital Medicine does not currently track the number of international medical graduates (IMGs) in the U.S. practicing hospital medicine, most authorities believe it’s between 20 and 25 percent of the current workforce. 2 Undoubtedly, many of these docs are already U.S. citizens, but most work in the U.S. on employer-sponsored programs (H1-B), with a few taking the J-1 visa tract. Both programs are often used as a catalyst to permanent residency, but the J-1 requires the individual to work in an underserved area for three years before being eligible.

Because the H-1B visa individual can only maintain this status for three years at a time for a maximum of six years, I’m assuming you used three years of the program to complete your residency and will either need to obtain permanent residency (a green card) very soon or will have to leave the country for at least a year before you can apply again. The law does grant extensions beyond this six-year period but only when certain parts of the green card process have been pending for one year prior to the requested H1-B start date.

Assuming you have no culpability for the delay in processing the application (e.g., you turned in necessary paperwork on time, responded timely to correspondence from processors), you have every right to be angry. The application process is tedious and very complex, with very rigid time constraints. Many organizations have used physicians with H-1B visas to fill the gaps in their recruiting without the necessary infrastructure to support the needs of this group. While I recognize it would be difficult for small groups or hospitals to afford knowledgeable and skilled support staff, the days of having part-time administrative support to manage this task are long gone. There are web-based organizations that are skilled and affordable for the smaller groups, and larger groups should invest in administrative staff to support their physicians with visas. After all, in this era of “we’re all part of the team,” it’s difficult to feel valued when your ability to borrow money or travel internationally is limited or even worse: You could be deported.

As an ex-military guy, following the chain of command is in my blood. However, if after given reasonable opportunity to assist and rectify your issues, the division director is unresponsive or unable to assist, I would escalate to the department chair and beyond if necessary.

Good luck! TH

References

1. U.S. Department of Homeland Security, U.S. Citizenship and Immigration Services. Characteristics of H1B Specialty Occupation Workers: Fiscal Year 21012 Annual Report to Congress. U.S. Citizenship and Immigration Services website. Accessed October 17, 2016
2. Educational Commission for Foreign Medical Graduates [10-06-2012];Annual Report.

   Accessed October 17, 2016

Dear Dr. Hospitalist:

I completed my residency approximately a year ago and was hired by a large academic hospital medicine program with an H-1B visa. After six to eight months in what I thought was the “application process” for permanent residency, I discovered that the people responsible for filing the necessary paperwork had not done anything. During this delayed application period, it is too risky to travel internationally. While I’m still gracious for the opportunity to train and work in the U.S., I am depressed and angry because I haven’t seen my family for almost two years. Should I escalate and complain about my situation beyond the director of my division or just sit back and wait it out?

Dr. Angry and in Limbo

Dr. Hospitalist responds:

There were 2,576 H-1B petitions approved for physicians and surgeons in FY 2012.1 Even though the Society of Hospital Medicine does not currently track the number of international medical graduates (IMGs) in the U.S. practicing hospital medicine, most authorities believe it’s between 20 and 25 percent of the current workforce. 2 Undoubtedly, many of these docs are already U.S. citizens, but most work in the U.S. on employer-sponsored programs (H1-B), with a few taking the J-1 visa tract. Both programs are often used as a catalyst to permanent residency, but the J-1 requires the individual to work in an underserved area for three years before being eligible.

Because the H-1B visa individual can only maintain this status for three years at a time for a maximum of six years, I’m assuming you used three years of the program to complete your residency and will either need to obtain permanent residency (a green card) very soon or will have to leave the country for at least a year before you can apply again. The law does grant extensions beyond this six-year period but only when certain parts of the green card process have been pending for one year prior to the requested H1-B start date.

Assuming you have no culpability for the delay in processing the application (e.g., you turned in necessary paperwork on time, responded timely to correspondence from processors), you have every right to be angry. The application process is tedious and very complex, with very rigid time constraints. Many organizations have used physicians with H-1B visas to fill the gaps in their recruiting without the necessary infrastructure to support the needs of this group. While I recognize it would be difficult for small groups or hospitals to afford knowledgeable and skilled support staff, the days of having part-time administrative support to manage this task are long gone. There are web-based organizations that are skilled and affordable for the smaller groups, and larger groups should invest in administrative staff to support their physicians with visas. After all, in this era of “we’re all part of the team,” it’s difficult to feel valued when your ability to borrow money or travel internationally is limited or even worse: You could be deported.

As an ex-military guy, following the chain of command is in my blood. However, if after given reasonable opportunity to assist and rectify your issues, the division director is unresponsive or unable to assist, I would escalate to the department chair and beyond if necessary.

Good luck! TH

References

1. U.S. Department of Homeland Security, U.S. Citizenship and Immigration Services. Characteristics of H1B Specialty Occupation Workers: Fiscal Year 21012 Annual Report to Congress. U.S. Citizenship and Immigration Services website. Accessed October 17, 2016
2. Educational Commission for Foreign Medical Graduates [10-06-2012];Annual Report.

   Accessed October 17, 2016

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

With my team, I use whiteboards as a tool to enhance communication: 1) I introduce myself and my team members, then write our names on the whiteboard paired with an explanation of my role as the attending physician for the hospital medicine service; 2) on a daily basis, I ask the patient and family/support what their primary concerns and goals are and write those on the whiteboard; and 3) I invite the patient and family/support to use the whiteboard to write additional concerns or questions as they arise.

Why I Do It

Hospitals are confusing places. One of our key roles as hospitalists is to coordinate and clarify all of the moving pieces and to communicate clearly to patients and their family that there is someone doing that work on their behalf. The whiteboard can help to accomplish that and to visually indicate “reflective listening.” If I ask patients what their concerns and goals are on a daily basis, I can better address them, and writing those on the whiteboard is a way to visually let patients know I have heard them—and heard them accurately. Finally, as we know from experience at our institution, when patients are invited to write on the whiteboard, they are likely to do so and will often write important information that hasn’t come up during routine rounding.

How I Do It

The key to effectiveness is to build whiteboard use into the clinical workflow and patient conversation rather than create an extra task to complete. I have developed a routine using the whiteboard that is more or less the same for every patient.

Also, whiteboard design can influence the use of the whiteboard as a communication tool. I favor designs that have few prescriptive boxes and more space for writing. I have found whiteboards labeled with a “What are your goals?” section to be helpful.

Patrick Kneeland, MD, is medical director for patient and provider experience and director of the Excellence in Communication Curriculum, University of Colorado Hospital and Clinics.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

With my team, I use whiteboards as a tool to enhance communication: 1) I introduce myself and my team members, then write our names on the whiteboard paired with an explanation of my role as the attending physician for the hospital medicine service; 2) on a daily basis, I ask the patient and family/support what their primary concerns and goals are and write those on the whiteboard; and 3) I invite the patient and family/support to use the whiteboard to write additional concerns or questions as they arise.

Why I Do It

Hospitals are confusing places. One of our key roles as hospitalists is to coordinate and clarify all of the moving pieces and to communicate clearly to patients and their family that there is someone doing that work on their behalf. The whiteboard can help to accomplish that and to visually indicate “reflective listening.” If I ask patients what their concerns and goals are on a daily basis, I can better address them, and writing those on the whiteboard is a way to visually let patients know I have heard them—and heard them accurately. Finally, as we know from experience at our institution, when patients are invited to write on the whiteboard, they are likely to do so and will often write important information that hasn’t come up during routine rounding.

How I Do It

The key to effectiveness is to build whiteboard use into the clinical workflow and patient conversation rather than create an extra task to complete. I have developed a routine using the whiteboard that is more or less the same for every patient.

Also, whiteboard design can influence the use of the whiteboard as a communication tool. I favor designs that have few prescriptive boxes and more space for writing. I have found whiteboards labeled with a “What are your goals?” section to be helpful.

Patrick Kneeland, MD, is medical director for patient and provider experience and director of the Excellence in Communication Curriculum, University of Colorado Hospital and Clinics.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

With my team, I use whiteboards as a tool to enhance communication: 1) I introduce myself and my team members, then write our names on the whiteboard paired with an explanation of my role as the attending physician for the hospital medicine service; 2) on a daily basis, I ask the patient and family/support what their primary concerns and goals are and write those on the whiteboard; and 3) I invite the patient and family/support to use the whiteboard to write additional concerns or questions as they arise.

Why I Do It

Hospitals are confusing places. One of our key roles as hospitalists is to coordinate and clarify all of the moving pieces and to communicate clearly to patients and their family that there is someone doing that work on their behalf. The whiteboard can help to accomplish that and to visually indicate “reflective listening.” If I ask patients what their concerns and goals are on a daily basis, I can better address them, and writing those on the whiteboard is a way to visually let patients know I have heard them—and heard them accurately. Finally, as we know from experience at our institution, when patients are invited to write on the whiteboard, they are likely to do so and will often write important information that hasn’t come up during routine rounding.

How I Do It

The key to effectiveness is to build whiteboard use into the clinical workflow and patient conversation rather than create an extra task to complete. I have developed a routine using the whiteboard that is more or less the same for every patient.

Also, whiteboard design can influence the use of the whiteboard as a communication tool. I favor designs that have few prescriptive boxes and more space for writing. I have found whiteboards labeled with a “What are your goals?” section to be helpful.

Patrick Kneeland, MD, is medical director for patient and provider experience and director of the Excellence in Communication Curriculum, University of Colorado Hospital and Clinics.

F. W. Erdman, Alabama

S. Baquai, MD, California

J. Bullock, California

A. Chong, MD, California

J. Decolongon, California

J. Do, MD, California

T. Farmer, ACNP, California

T. Holden, MD, California

M. Khare, California

P. Lally, MD, California

B. Lee, MD, California

J. Lee, MD, California

A. Mannan, MD, California

N. Pandher, California

E. Park, CaliforniaB. Patel, USA, California

N. Patel, California

S. Singh, MD, California

M. Vakili, California

A. Zandpour, AHIP, California

L. Chong, MD, FACP, Connecticut

G. Cudjoe, MBBS, Connecticut

S. Gazi, MD, Connecticut

S. Pattisapu, Connecticut

M. Rai, Connecticut

S. Roshan, MD, Connecticut

A. Seye, MD, Connecticut

L. Zheng, Connecticut

S. Raghavan, MD, PhD, Colorado

M. Altieri, MHSc, PA-C, Florida

M. Bishai, DO, Florida

B. Burns, Florida

A. Chan, MD, Florida

M. Cuk, Florida

S. Epps, DO, Florida

N. Fedotova, PhD, Florida

A. Lee, MD, Florida

M. Ruiz, Florida

D. Britt, Georgia

W. Futch, Georgia

B. Kruszewski, Georgia

I. Lowell, MD, MBA, Georgia

Y. Patel, MD, Georgia

G. Polk-Seldon, FNP, Georgia

T. Truong, MD, Georgia

J. Walker, DO, Georgia

S. Wang, MBA, Georgia

S. Del Mundo, Hawaii

T. Hiura, MD, Hawaii

D. Orchard, Idaho

S. Pontickio, MD, Idaho

R. Antoine, MD, Illinois

A. Baid, Illinois

C. Boyle, MD, Illinois

M. Delibasic, MD, Illinois

J. Gemson, Illinois

J. Mechurova, MD, Illinois

T. Morales, Illinois

H. Omar, Illinois

B. Pathak, MD, Illinois

S. Rao, MD, Illinois

Z. Ritchey, Illinois

A. Veerabahu, Illinois

T. Barley, MD, Indiana

M. Meyer, ACNP, MSN, Indiana

D. Ross, MA, Indiana

K. Sorg, MD, Indiana

A. Evans, Iowa

R. Miller, MD, Louisiana

D. Pollet, MD, Louisiana

J. Goldberg, MD, Maine

S. Gutierrez, MD, Maine

K. Osborne, FNP, Maine

V. Pramanik, MD, Maine

C. Sherpa, Maine

H. Abinader, Maryland

I. Pena, Maryland

D. Press, MD, Maryland

D. Soffer, Maryland

J. Bennett, FAAP, Massachusetts

N. Howe, ACNP, Massachusetts

J. Hudspeth, MD, Massachusetts

I. Ismail, MD, Massachusetts

B. Lall, MD, Massachusetts

M. Lawler, MD, Massachusetts

E. O’Fallon, MD, Massachusetts

J. Ringwala, Massachusetts

M. Soe, MD, Massachusetts

E. Sweatt, MD, Massachusetts

M. Trivedi, Massachusetts

E. Chappe, MD, Michigan

A. Goyal, MD, Michigan

E. Hunter, DO, Michigan

S. Malewskim ACNP, MSN, RN, Michigan

W. Ladner, Minnesota

J. Purdy, Minnesota

T. VanLith, PA-C, Minnesota

P. Acharya, MBBS, Mississippi

A. Ladd, CNP, Mississippi

S. Morris, DO, MBA, Mississippi

R. Walters, DO, Mississippi

R. Allen, DO, Missouri

L. Andrea, MissouriA. Arnaud, Missouri

M. Board, Missouri

S. Njagi, MD, FAAFP, MBchB, Missouri

J. Patel, Missouri

A. Roman, MD, Missouri

R. Singh, Missouri

F. Wang, Missouri

S. Byington, MD, Montana

T. Lloyd, Montana

B. Bulian, MD, Nebraska

S. Adagi, New Jersey

C. Cristescu, MeD, New Jersey

A. Malhotra, MD, New Jersey

K. Patel, DO, New Jersey

S. Terner, MD, New Jersey

H. Alqam, New Mexico

A. Attreya, DO, New Mexico

K. Avila, New Mexico

K. Chan, New Mexico

S. Montano, New Mexico

C. Morales, New Mexico

A. Stecker, New Mexico

D. Varela, New Mexico

M. Ahmed, MD, New York

G. Apergis, MD, New York

J. Dekhtyar, MD, New York

J. Dillon, New York

N. Jaglall, MD, New YorkL. Kruzhkov, New York

R. Malhan, MD, New York

J. Mathew, New YorkV. Miro, New York

B. Gautam, North Carolina

K. Gold, MD, North Carolina P. Greene, MD, North Carolina

S. Grotzke, North Carolina

S. Hester, MD, North Carolina

P. Le, MD, North Carolina

J. McClung, MD, North Carolina

J. Ramsey, MD, North Carolina

J. Sullivan, DO, North Carolina

C. Chadwell, Ohio

R. Dash, MD, Ohio

E. Ofungwu, USAR, Ohio

R. Raj, MD, Ohio

I. Rawal, Ohio

N. Beach, DO, Oregon

M. Christensen, ACNP, Oregon

K. Haugen, MD, Oregon

J. Luty, MD, Oregon

K. Andersen, Pennsylvania

O. Ball, MD, Pennsylvania

S. Harris, DO, Pennsylvania

R. Koubek, Pennsylvania

B. Krug, MHA, Pennsylvania

A. Levin, MD, Pennsylvania

A. Marwah, Pennsylvania

D. McAllister, FNP, Pennsylvania

C. Sakosky, FNP, Pennsylvania

J. Steffl, PA-C, Pennsylvania

A. Sukits, MS, PA-C, Pennsylvania

S. Clemens, Rhode Island

C. Drasny, MD, South Carolina

J. Harris, MD, South Carolina

D. Head, MD, South Carolina

S. Johnson, South Carolina

A. Evjen, MD, South Dakota

P. Pate, Tennessee

J. Patterson, ACNP-BC, MSN, Tennessee

A. Seth, MD, Tennessee

P. Boeckmann, FACHE, Texas

M. Gupta, Texas

J. Jain, MD, Texas

K. Roberts, Texas

C. Romero, MD, PhD, Texas

D. Buzanoski, MD, Utah

N. Whitaker, FACP, Utah

E. Greenberger, MD, Vermont

R. McEntee, MD, Vermont

C. Rickman, FACP, Vermont

W. Austin, MSHA, Virginia

E. Orshansky, MD, Virginia

G. Psarros, MD, Virginia

N. Trivedi, Virginia

E. Addison, Washington

J. Gifford, PA-C, Washington

V. Johnson, ARNP, CFNP, MHSc, Washington

C. Wang, MD, Washington

M. Brown, West Virginia

V. Raina, MD, Wisconsin

F. Germa, MD, CCP(EM), FCEP (C), Canada

J. Podavin, Canada

K. Slatkovsky, Canada

M. Kitamura, Japan

M. Rafei, Oman

F. W. Erdman, Alabama

S. Baquai, MD, California

J. Bullock, California

A. Chong, MD, California

J. Decolongon, California

J. Do, MD, California

T. Farmer, ACNP, California

T. Holden, MD, California

M. Khare, California

P. Lally, MD, California

B. Lee, MD, California

J. Lee, MD, California

A. Mannan, MD, California

N. Pandher, California

E. Park, CaliforniaB. Patel, USA, California

N. Patel, California

S. Singh, MD, California

M. Vakili, California

A. Zandpour, AHIP, California

L. Chong, MD, FACP, Connecticut

G. Cudjoe, MBBS, Connecticut

S. Gazi, MD, Connecticut

S. Pattisapu, Connecticut

M. Rai, Connecticut

S. Roshan, MD, Connecticut

A. Seye, MD, Connecticut

L. Zheng, Connecticut

S. Raghavan, MD, PhD, Colorado

M. Altieri, MHSc, PA-C, Florida

M. Bishai, DO, Florida

B. Burns, Florida

A. Chan, MD, Florida

M. Cuk, Florida

S. Epps, DO, Florida

N. Fedotova, PhD, Florida

A. Lee, MD, Florida

M. Ruiz, Florida

D. Britt, Georgia

W. Futch, Georgia

B. Kruszewski, Georgia

I. Lowell, MD, MBA, Georgia

Y. Patel, MD, Georgia

G. Polk-Seldon, FNP, Georgia

T. Truong, MD, Georgia

J. Walker, DO, Georgia

S. Wang, MBA, Georgia

S. Del Mundo, Hawaii

T. Hiura, MD, Hawaii

D. Orchard, Idaho

S. Pontickio, MD, Idaho

R. Antoine, MD, Illinois

A. Baid, Illinois

C. Boyle, MD, Illinois

M. Delibasic, MD, Illinois

J. Gemson, Illinois

J. Mechurova, MD, Illinois

T. Morales, Illinois

H. Omar, Illinois

B. Pathak, MD, Illinois

S. Rao, MD, Illinois

Z. Ritchey, Illinois

A. Veerabahu, Illinois

T. Barley, MD, Indiana

M. Meyer, ACNP, MSN, Indiana

D. Ross, MA, Indiana

K. Sorg, MD, Indiana

A. Evans, Iowa

R. Miller, MD, Louisiana

D. Pollet, MD, Louisiana

J. Goldberg, MD, Maine

S. Gutierrez, MD, Maine

K. Osborne, FNP, Maine

V. Pramanik, MD, Maine

C. Sherpa, Maine

H. Abinader, Maryland

I. Pena, Maryland

D. Press, MD, Maryland

D. Soffer, Maryland

J. Bennett, FAAP, Massachusetts

N. Howe, ACNP, Massachusetts

J. Hudspeth, MD, Massachusetts

I. Ismail, MD, Massachusetts

B. Lall, MD, Massachusetts

M. Lawler, MD, Massachusetts

E. O’Fallon, MD, Massachusetts

J. Ringwala, Massachusetts

M. Soe, MD, Massachusetts

E. Sweatt, MD, Massachusetts

M. Trivedi, Massachusetts

E. Chappe, MD, Michigan

A. Goyal, MD, Michigan

E. Hunter, DO, Michigan

S. Malewskim ACNP, MSN, RN, Michigan

W. Ladner, Minnesota

J. Purdy, Minnesota

T. VanLith, PA-C, Minnesota

P. Acharya, MBBS, Mississippi

A. Ladd, CNP, Mississippi

S. Morris, DO, MBA, Mississippi

R. Walters, DO, Mississippi

R. Allen, DO, Missouri

L. Andrea, MissouriA. Arnaud, Missouri

M. Board, Missouri

S. Njagi, MD, FAAFP, MBchB, Missouri

J. Patel, Missouri

A. Roman, MD, Missouri

R. Singh, Missouri

F. Wang, Missouri

S. Byington, MD, Montana

T. Lloyd, Montana

B. Bulian, MD, Nebraska

S. Adagi, New Jersey

C. Cristescu, MeD, New Jersey

A. Malhotra, MD, New Jersey

K. Patel, DO, New Jersey

S. Terner, MD, New Jersey

H. Alqam, New Mexico

A. Attreya, DO, New Mexico

K. Avila, New Mexico

K. Chan, New Mexico

S. Montano, New Mexico

C. Morales, New Mexico

A. Stecker, New Mexico

D. Varela, New Mexico

M. Ahmed, MD, New York

G. Apergis, MD, New York

J. Dekhtyar, MD, New York

J. Dillon, New York

N. Jaglall, MD, New YorkL. Kruzhkov, New York

R. Malhan, MD, New York

J. Mathew, New YorkV. Miro, New York

B. Gautam, North Carolina

K. Gold, MD, North Carolina P. Greene, MD, North Carolina

S. Grotzke, North Carolina

S. Hester, MD, North Carolina

P. Le, MD, North Carolina

J. McClung, MD, North Carolina

J. Ramsey, MD, North Carolina

J. Sullivan, DO, North Carolina

C. Chadwell, Ohio

R. Dash, MD, Ohio

E. Ofungwu, USAR, Ohio

R. Raj, MD, Ohio

I. Rawal, Ohio

N. Beach, DO, Oregon

M. Christensen, ACNP, Oregon

K. Haugen, MD, Oregon

J. Luty, MD, Oregon

K. Andersen, Pennsylvania

O. Ball, MD, Pennsylvania

S. Harris, DO, Pennsylvania

R. Koubek, Pennsylvania

B. Krug, MHA, Pennsylvania

A. Levin, MD, Pennsylvania

A. Marwah, Pennsylvania

D. McAllister, FNP, Pennsylvania

C. Sakosky, FNP, Pennsylvania

J. Steffl, PA-C, Pennsylvania

A. Sukits, MS, PA-C, Pennsylvania

S. Clemens, Rhode Island

C. Drasny, MD, South Carolina

J. Harris, MD, South Carolina

D. Head, MD, South Carolina

S. Johnson, South Carolina

A. Evjen, MD, South Dakota

P. Pate, Tennessee

J. Patterson, ACNP-BC, MSN, Tennessee

A. Seth, MD, Tennessee

P. Boeckmann, FACHE, Texas

M. Gupta, Texas

J. Jain, MD, Texas

K. Roberts, Texas

C. Romero, MD, PhD, Texas

D. Buzanoski, MD, Utah

N. Whitaker, FACP, Utah

E. Greenberger, MD, Vermont

R. McEntee, MD, Vermont

C. Rickman, FACP, Vermont

W. Austin, MSHA, Virginia

E. Orshansky, MD, Virginia

G. Psarros, MD, Virginia

N. Trivedi, Virginia

E. Addison, Washington

J. Gifford, PA-C, Washington

V. Johnson, ARNP, CFNP, MHSc, Washington

C. Wang, MD, Washington

M. Brown, West Virginia

V. Raina, MD, Wisconsin

F. Germa, MD, CCP(EM), FCEP (C), Canada

J. Podavin, Canada

K. Slatkovsky, Canada

M. Kitamura, Japan

M. Rafei, Oman

F. W. Erdman, Alabama

S. Baquai, MD, California

J. Bullock, California

A. Chong, MD, California

J. Decolongon, California

J. Do, MD, California

T. Farmer, ACNP, California

T. Holden, MD, California

M. Khare, California

P. Lally, MD, California

B. Lee, MD, California

J. Lee, MD, California

A. Mannan, MD, California

N. Pandher, California

E. Park, CaliforniaB. Patel, USA, California

N. Patel, California

S. Singh, MD, California

M. Vakili, California

A. Zandpour, AHIP, California

L. Chong, MD, FACP, Connecticut

G. Cudjoe, MBBS, Connecticut

S. Gazi, MD, Connecticut

S. Pattisapu, Connecticut

M. Rai, Connecticut

S. Roshan, MD, Connecticut

A. Seye, MD, Connecticut

L. Zheng, Connecticut

S. Raghavan, MD, PhD, Colorado

M. Altieri, MHSc, PA-C, Florida

M. Bishai, DO, Florida

B. Burns, Florida

A. Chan, MD, Florida

M. Cuk, Florida

S. Epps, DO, Florida

N. Fedotova, PhD, Florida

A. Lee, MD, Florida

M. Ruiz, Florida

D. Britt, Georgia

W. Futch, Georgia

B. Kruszewski, Georgia

I. Lowell, MD, MBA, Georgia

Y. Patel, MD, Georgia

G. Polk-Seldon, FNP, Georgia

T. Truong, MD, Georgia

J. Walker, DO, Georgia

S. Wang, MBA, Georgia

S. Del Mundo, Hawaii

T. Hiura, MD, Hawaii

D. Orchard, Idaho

S. Pontickio, MD, Idaho

R. Antoine, MD, Illinois

A. Baid, Illinois

C. Boyle, MD, Illinois

M. Delibasic, MD, Illinois

J. Gemson, Illinois

J. Mechurova, MD, Illinois

T. Morales, Illinois

H. Omar, Illinois

B. Pathak, MD, Illinois

S. Rao, MD, Illinois

Z. Ritchey, Illinois

A. Veerabahu, Illinois

T. Barley, MD, Indiana

M. Meyer, ACNP, MSN, Indiana

D. Ross, MA, Indiana

K. Sorg, MD, Indiana

A. Evans, Iowa

R. Miller, MD, Louisiana

D. Pollet, MD, Louisiana

J. Goldberg, MD, Maine

S. Gutierrez, MD, Maine

K. Osborne, FNP, Maine

V. Pramanik, MD, Maine

C. Sherpa, Maine

H. Abinader, Maryland

I. Pena, Maryland

D. Press, MD, Maryland

D. Soffer, Maryland

J. Bennett, FAAP, Massachusetts

N. Howe, ACNP, Massachusetts

J. Hudspeth, MD, Massachusetts

I. Ismail, MD, Massachusetts

B. Lall, MD, Massachusetts

M. Lawler, MD, Massachusetts

E. O’Fallon, MD, Massachusetts

J. Ringwala, Massachusetts

M. Soe, MD, Massachusetts

E. Sweatt, MD, Massachusetts

M. Trivedi, Massachusetts

E. Chappe, MD, Michigan

A. Goyal, MD, Michigan

E. Hunter, DO, Michigan

S. Malewskim ACNP, MSN, RN, Michigan

W. Ladner, Minnesota

J. Purdy, Minnesota

T. VanLith, PA-C, Minnesota

P. Acharya, MBBS, Mississippi

A. Ladd, CNP, Mississippi

S. Morris, DO, MBA, Mississippi

R. Walters, DO, Mississippi

R. Allen, DO, Missouri

L. Andrea, MissouriA. Arnaud, Missouri

M. Board, Missouri

S. Njagi, MD, FAAFP, MBchB, Missouri

J. Patel, Missouri

A. Roman, MD, Missouri

R. Singh, Missouri

F. Wang, Missouri

S. Byington, MD, Montana

T. Lloyd, Montana

B. Bulian, MD, Nebraska

S. Adagi, New Jersey

C. Cristescu, MeD, New Jersey

A. Malhotra, MD, New Jersey

K. Patel, DO, New Jersey

S. Terner, MD, New Jersey

H. Alqam, New Mexico

A. Attreya, DO, New Mexico

K. Avila, New Mexico

K. Chan, New Mexico

S. Montano, New Mexico

C. Morales, New Mexico

A. Stecker, New Mexico

D. Varela, New Mexico

M. Ahmed, MD, New York

G. Apergis, MD, New York

J. Dekhtyar, MD, New York

J. Dillon, New York

N. Jaglall, MD, New YorkL. Kruzhkov, New York

R. Malhan, MD, New York

J. Mathew, New YorkV. Miro, New York

B. Gautam, North Carolina

K. Gold, MD, North Carolina P. Greene, MD, North Carolina

S. Grotzke, North Carolina

S. Hester, MD, North Carolina

P. Le, MD, North Carolina

J. McClung, MD, North Carolina

J. Ramsey, MD, North Carolina

J. Sullivan, DO, North Carolina

C. Chadwell, Ohio

R. Dash, MD, Ohio

E. Ofungwu, USAR, Ohio

R. Raj, MD, Ohio

I. Rawal, Ohio

N. Beach, DO, Oregon

M. Christensen, ACNP, Oregon

K. Haugen, MD, Oregon

J. Luty, MD, Oregon

K. Andersen, Pennsylvania

O. Ball, MD, Pennsylvania

S. Harris, DO, Pennsylvania

R. Koubek, Pennsylvania

B. Krug, MHA, Pennsylvania

A. Levin, MD, Pennsylvania

A. Marwah, Pennsylvania

D. McAllister, FNP, Pennsylvania

C. Sakosky, FNP, Pennsylvania

J. Steffl, PA-C, Pennsylvania

A. Sukits, MS, PA-C, Pennsylvania

S. Clemens, Rhode Island

C. Drasny, MD, South Carolina

J. Harris, MD, South Carolina

D. Head, MD, South Carolina

S. Johnson, South Carolina

A. Evjen, MD, South Dakota

P. Pate, Tennessee

J. Patterson, ACNP-BC, MSN, Tennessee

A. Seth, MD, Tennessee

P. Boeckmann, FACHE, Texas

M. Gupta, Texas

J. Jain, MD, Texas

K. Roberts, Texas

C. Romero, MD, PhD, Texas

D. Buzanoski, MD, Utah

N. Whitaker, FACP, Utah

E. Greenberger, MD, Vermont

R. McEntee, MD, Vermont

C. Rickman, FACP, Vermont

W. Austin, MSHA, Virginia

E. Orshansky, MD, Virginia

G. Psarros, MD, Virginia

N. Trivedi, Virginia

E. Addison, Washington

J. Gifford, PA-C, Washington

V. Johnson, ARNP, CFNP, MHSc, Washington

C. Wang, MD, Washington

M. Brown, West Virginia

V. Raina, MD, Wisconsin

F. Germa, MD, CCP(EM), FCEP (C), Canada

J. Podavin, Canada

K. Slatkovsky, Canada

M. Kitamura, Japan

M. Rafei, Oman

One recent paper in Clinical Pediatrics, for example, chronicled low adherence to the 2011 National Heart, Lung, and Blood Institute lipid screening guidelines in primary-care settings.1 Another cautioned providers to “mind the (implementation) gap” in venous thromboembolism prevention guidelines for medical inpatients.2 A third found that lower adherence to guidelines issued by the American College of Cardiology/American Heart Association for acute coronary syndrome patients was significantly associated with higher bleeding and mortality rates.3

Both clinical trials and real-world studies have demonstrated that when guidelines are applied, patients do better, says William Lewis, MD, professor of medicine at Case Western Reserve University and director of the Heart & Vascular Center at MetroHealth in Cleveland. So why aren’t they followed more consistently?

Experts in both HM and other disciplines cite multiple obstacles. Lack of evidence, conflicting evidence, or lack of awareness about evidence can all conspire against the main goal of helping providers deliver consistent high-value care, says Christopher Moriates, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

“In our day-to-day lives as hospitalists, for the vast majority probably of what we do there’s no clear guideline or there’s a guideline that doesn’t necessarily apply to the patient standing in front of me,” he says.

Even when a guideline is clear and relevant, other doctors say inadequate dissemination and implementation can still derail quality improvement efforts.

“A lot of what we do as physicians is what we learned in residency, and to incorporate the new data is difficult,” says Leonard Feldman, MD, SFHM, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore.

Dr. Feldman believes many doctors have yet to integrate recently revised hypertension and cholesterol guidelines into their practice, for example. Some guidelines have proven more complex or controversial, limiting their adoption.

“I know I struggle to keep up with all of the guidelines, and I’m in a big academic center where people are talking about them all the time, and I’m working with residents who are talking about them all the time,” Dr. Feldman says.

Despite the remaining gaps, however, many researchers agree that momentum has built steadily over the past two decades toward a more systematic approach to creating solid evidence-based guidelines and integrating them into real-world decision making.

Emphasis on Evidence and Transparency

The term “evidence-based medicine” was coined in 1990 by Gordon Guyatt, MD, MSc, FRCPC, distinguished professor of medicine and clinical epidemiology at McMaster University in Hamilton, Ontario. It’s played an active role in formulating guidelines for multiple organizations. The guideline-writing process, Dr. Guyatt says, once consisted of little more than self-selected clinicians sitting around a table.

“It used to be that a bunch of experts got together and decided and made the recommendations with very little in the way of a systematic process and certainly not evidence based,” he says.

Cincinnati Children’s Hospital Medical Center was among the pioneers pushing for a more systematic approach; the hospital began working on its own guidelines in 1995 and published the first of many the following year.

“We started evidence-based guidelines when the docs were still saying, ‘This is cookbook medicine. I don’t know if I want to do this or not,’” says Wendy Gerhardt, MSN, director of evidence-based decision making in the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s.

Some doctors also argued that clinical guidelines would stifle innovation, cramp their individual style, or intrude on their relationships with patients. Despite some lingering misgivings among clinicians, however, the process has gained considerable support. In 2000, an organization called the GRADE Working Group (Grading of Recommendations, Assessment, Development and Evaluation) began developing a new approach to raise the quality of evidence and strength of recommendations.

The group’s work led to a 2004 article in BMJ, and the journal subsequently published a six-part series about GRADE for clinicians.4 More recently, the Journal of Clinical Epidemiology also delved into the issue with a 15-part series detailing the GRADE methodology.5 Together, Dr. Guyatt says, the articles have become a go-to guide for guidelines and have helped solidify the focus on evidence.

Cincinnati Children’s and other institutions also have developed tools, and the Institute of Medicine has published guideline-writing standards.

“So it’s easier than it’s ever been to know whether or not you have a decent guideline in your hand,” Gerhardt says.

Likewise, medical organizations are more clearly explaining how they came up with different kinds of guidelines. Evidence-based and consensus guidelines aren’t necessarily mutually exclusive, though consensus building is often used in the absence of high-quality evidence. Some organizations have limited the pool of evidence for guidelines to randomized controlled trial data.

“Unfortunately, for us in the real world, we actually have to make decisions even when there’s not enough data,” Dr. Feldman says.

Sometimes, the best available evidence may be observational studies, and some committees still try to reach a consensus based on that evidence and on the panelists’ professional opinions.

Dr. Guyatt agrees that it’s “absolutely not” true that evidence-based guidelines require randomized controlled trials. “What you need for any recommendation is a thorough review and summary of the best available evidence,” he says.

As part of each final document, Cincinnati Children’s details how it created the guideline, when the literature searches occurred, how the committee reached a consensus, and which panelists participated in the deliberations. The information, Gerhardt says, allows anyone else to “make some sensible decisions about whether or not it’s a guideline you want to use.”

Guideline-crafting institutions are also focusing more on the proper makeup of their panels. In general, Dr. Guyatt says, a panel with more than 10 people can be unwieldy. Guidelines that include many specific recommendations, however, may require multiple subsections, each with its own committee.

Dr. Guyatt is careful to note that, like many other experts, he has multiple potential conflicts of interest, such as working on the anti-thrombotic guidelines issued by the American College of Chest Physicians. Committees, he says, have become increasingly aware of how properly handling conflicts (financial or otherwise) can be critical in building and maintaining trust among clinicians and patients. One technique is to ensure that a diversity of opinions is reflected among a committee whose experts have various conflicts. If one expert’s company makes drug A, for example, then the committee also includes experts involved with drugs B or C. As an alternative, some committees have explicitly barred anyone with a conflict of interest from participating at all.

But experts often provide crucial input, Dr. Guyatt says, and several committees have adopted variations of a middle-ground approach. In an approach that he favors, all guideline-formulating panelists are conflict-free but begin their work by meeting with a separate group of experts who may have some conflicts but can help point out the main issues. The panelists then deliberate and write a draft of the recommendations, after which they meet again with the experts to receive feedback before finalizing the draft.

In a related approach, experts sit on the panel and discuss the evidence, but those with conflicts recuse themselves before the group votes on any recommendations. Delineating between discussions of the evidence and discussions of recommendations can be tricky, though, increasing the risk that a conflict of interest may influence the outcome. Even so, Dr. Guyatt says the model is still preferable to other alternatives.

Getting the Word Out

Once guidelines have been crafted and vetted, how can hospitalists get up to speed on them? Dr. Feldman’s favorite go-to source is Guideline.gov, a national guideline clearinghouse that he calls one of the best compendiums of available information. Especially helpful, he adds, are details such as how the guidelines were created.

To help maximize his time, he also uses tools like NEJM Journal Watch, which sends daily emails on noteworthy articles and weekend roundups of the most important studies.

“It is a way of at least trying to keep up with what’s going on,” he says. Similarly, he adds, ACP Journal Club provides summaries of important new articles, The Hospitalist can help highlight important guidelines that affect HM, and CME meetings or online modules like SHMconsults.com can help doctors keep pace.

For the past decade, Dr. Guyatt has worked with another popular tool, a guideline-disseminating service called UpToDate. Many alternatives exist, such as DynaMed Plus.

“I think you just need to pick away,” Dr. Feldman says. “You need to decide that as a physician, as a lifelong learner, that you are going to do something that is going to keep you up-to-date. There are many ways of doing it. You just have to decide what you’re going to do and commit to it.”

Researchers are helping out by studying how to present new guidelines in ways that engage doctors and improve patient outcomes. Another trend is to make guidelines routinely accessible not only in electronic medical records but also on tablets and smartphones. Lisa Shieh, MD, PhD, FHM, a hospitalist and clinical professor of medicine at Stanford University Medical Center, has studied how best-practice alerts, or BPAs, impact adherence to guidelines covering the appropriate use of blood products. Dr. Shieh, who splits her time between quality improvement and hospital medicine, says getting new information and guidelines into clinicians’ hands can be a logistical challenge.

“At Stanford, we had a huge official campaign around the guidelines, and that did make some impact, but it wasn’t huge in improving appropriate blood use,” she says. When the medial center set up a BPA through the electronic medical record system, however, both overall and inappropriate blood use declined significantly. In fact, the percentage of providers ordering blood products for patients with a hemoglobin count above 8 g/dL dropped from 60% to 25%.6

One difference maker, Dr. Shieh says, was providing education at the moment a doctor actually ordered blood. To avoid alert fatigue, the “smart BPA” fires only if a doctor tries to order blood and the patient’s hemoglobin is greater than 7 or 8 g/dL, depending on the diagnosis. If the doctor still wants to transfuse, the system requests a clinical indication for the exception.

Despite the clear improvement in appropriate use, the team wanted to understand why 25% of providers were still ordering blood products for patients with a hemoglobin count greater than 8 despite the triggered BPA and whether additional interventions could yield further improvements. Through their study, the researchers documented several reasons for the continued ordering. In some cases, the system failed to properly document actual or potential bleeding as an indicator. In other cases, the ordering reflected a lack of consensus on the guidelines in fields like hematology and oncology.

One of the most intriguing reasons, though, was that residents often did the ordering at the behest of an attending who might have never seen the BPA.

“It’s not actually reaching the audience making the decision; it might be reaching the audience that’s just carrying out the order,” Dr. Shieh says.

The insight, she says, may provide an opportunity to talk with attending physicians who may not have completely bought into the guidelines and to involve the entire team in the decision-making process.

Hospitalists, she says, can play a vital role in guideline development and implementation, especially for strategies that include BPAs.

“I think they’re the perfect group to help use this technology wisely because they are at the front lines taking care of patients so they’ll know the best workflow of when these alerts fire and maybe which ones happen the most often,” Dr. Shieh says. “I think this is a fantastic opportunity to get more hospitalists involved in designing these alerts and collaborating with the IT folks.”

Even with widespread buy-in from providers, guidelines may not reach their full potential without a careful consideration of patients’ values and concerns. Experts say joint deliberations and discussions are especially important for guidelines that are complicated, controversial, or carrying potential risks that must be weighed against the benefits.

Some of the conversations are easy, with well-defined risks and benefits and clear patient preferences, but others must traverse vast tracts of gray area. Fortunately, Dr. Feldman says, more tools also are becoming available for this kind of shared decision making. Some use pictorial representations to help patients understand the potential outcomes of alternative courses of action or inaction.

“Sometimes, that pictorial representation is worth the 1,000 words that we wouldn’t be able to adequately describe otherwise,” he says.

Similarly, Cincinnati Children’s has developed tools to help to ease the shared decision-making process.

“We look where there’s equivocal evidence or no evidence and have developed tools that help the clinician have that conversation with the family and then have them informed enough that they can actually weigh in on what they want,” Gerhardt says. One end product is a card or trifold pamphlet that might help parents understand the benefits and side effects of alternate strategies.

“Typically, in medicine, we’re used to telling people what needs to be done,” she says. “So shared decision making is kind of a different thing for clinicians to engage in.” TH

Bryn Nelson, PhD, is a freelance writer in Seattle.

References

1. Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Physicians’ lack of adherence to National Heart, Lung, and Blood Institute guidelines for pediatric lipid screening. Clin Pediatr. 2015;54(12):1200-1205.
2. Maynard G, Jenkins IH, Merli GJ. Venous thromboembolism prevention guidelines for medical inpatients: mind the (implementation) gap. J Hosp Med. 2013;8(10):582-588.
3. Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Circulation. 2015;131(11):980-987.
4. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726-735.
6. 6. Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med. 2015;10(1):1-7.

One recent paper in Clinical Pediatrics, for example, chronicled low adherence to the 2011 National Heart, Lung, and Blood Institute lipid screening guidelines in primary-care settings.1 Another cautioned providers to “mind the (implementation) gap” in venous thromboembolism prevention guidelines for medical inpatients.2 A third found that lower adherence to guidelines issued by the American College of Cardiology/American Heart Association for acute coronary syndrome patients was significantly associated with higher bleeding and mortality rates.3

Both clinical trials and real-world studies have demonstrated that when guidelines are applied, patients do better, says William Lewis, MD, professor of medicine at Case Western Reserve University and director of the Heart & Vascular Center at MetroHealth in Cleveland. So why aren’t they followed more consistently?

Experts in both HM and other disciplines cite multiple obstacles. Lack of evidence, conflicting evidence, or lack of awareness about evidence can all conspire against the main goal of helping providers deliver consistent high-value care, says Christopher Moriates, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

“In our day-to-day lives as hospitalists, for the vast majority probably of what we do there’s no clear guideline or there’s a guideline that doesn’t necessarily apply to the patient standing in front of me,” he says.

Even when a guideline is clear and relevant, other doctors say inadequate dissemination and implementation can still derail quality improvement efforts.

“A lot of what we do as physicians is what we learned in residency, and to incorporate the new data is difficult,” says Leonard Feldman, MD, SFHM, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore.

Dr. Feldman believes many doctors have yet to integrate recently revised hypertension and cholesterol guidelines into their practice, for example. Some guidelines have proven more complex or controversial, limiting their adoption.

“I know I struggle to keep up with all of the guidelines, and I’m in a big academic center where people are talking about them all the time, and I’m working with residents who are talking about them all the time,” Dr. Feldman says.

Despite the remaining gaps, however, many researchers agree that momentum has built steadily over the past two decades toward a more systematic approach to creating solid evidence-based guidelines and integrating them into real-world decision making.

Emphasis on Evidence and Transparency

The term “evidence-based medicine” was coined in 1990 by Gordon Guyatt, MD, MSc, FRCPC, distinguished professor of medicine and clinical epidemiology at McMaster University in Hamilton, Ontario. It’s played an active role in formulating guidelines for multiple organizations. The guideline-writing process, Dr. Guyatt says, once consisted of little more than self-selected clinicians sitting around a table.

“It used to be that a bunch of experts got together and decided and made the recommendations with very little in the way of a systematic process and certainly not evidence based,” he says.

Cincinnati Children’s Hospital Medical Center was among the pioneers pushing for a more systematic approach; the hospital began working on its own guidelines in 1995 and published the first of many the following year.

“We started evidence-based guidelines when the docs were still saying, ‘This is cookbook medicine. I don’t know if I want to do this or not,’” says Wendy Gerhardt, MSN, director of evidence-based decision making in the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s.

Some doctors also argued that clinical guidelines would stifle innovation, cramp their individual style, or intrude on their relationships with patients. Despite some lingering misgivings among clinicians, however, the process has gained considerable support. In 2000, an organization called the GRADE Working Group (Grading of Recommendations, Assessment, Development and Evaluation) began developing a new approach to raise the quality of evidence and strength of recommendations.

The group’s work led to a 2004 article in BMJ, and the journal subsequently published a six-part series about GRADE for clinicians.4 More recently, the Journal of Clinical Epidemiology also delved into the issue with a 15-part series detailing the GRADE methodology.5 Together, Dr. Guyatt says, the articles have become a go-to guide for guidelines and have helped solidify the focus on evidence.

Cincinnati Children’s and other institutions also have developed tools, and the Institute of Medicine has published guideline-writing standards.

“So it’s easier than it’s ever been to know whether or not you have a decent guideline in your hand,” Gerhardt says.

Likewise, medical organizations are more clearly explaining how they came up with different kinds of guidelines. Evidence-based and consensus guidelines aren’t necessarily mutually exclusive, though consensus building is often used in the absence of high-quality evidence. Some organizations have limited the pool of evidence for guidelines to randomized controlled trial data.

“Unfortunately, for us in the real world, we actually have to make decisions even when there’s not enough data,” Dr. Feldman says.

Sometimes, the best available evidence may be observational studies, and some committees still try to reach a consensus based on that evidence and on the panelists’ professional opinions.

Dr. Guyatt agrees that it’s “absolutely not” true that evidence-based guidelines require randomized controlled trials. “What you need for any recommendation is a thorough review and summary of the best available evidence,” he says.

As part of each final document, Cincinnati Children’s details how it created the guideline, when the literature searches occurred, how the committee reached a consensus, and which panelists participated in the deliberations. The information, Gerhardt says, allows anyone else to “make some sensible decisions about whether or not it’s a guideline you want to use.”

Guideline-crafting institutions are also focusing more on the proper makeup of their panels. In general, Dr. Guyatt says, a panel with more than 10 people can be unwieldy. Guidelines that include many specific recommendations, however, may require multiple subsections, each with its own committee.

Dr. Guyatt is careful to note that, like many other experts, he has multiple potential conflicts of interest, such as working on the anti-thrombotic guidelines issued by the American College of Chest Physicians. Committees, he says, have become increasingly aware of how properly handling conflicts (financial or otherwise) can be critical in building and maintaining trust among clinicians and patients. One technique is to ensure that a diversity of opinions is reflected among a committee whose experts have various conflicts. If one expert’s company makes drug A, for example, then the committee also includes experts involved with drugs B or C. As an alternative, some committees have explicitly barred anyone with a conflict of interest from participating at all.

But experts often provide crucial input, Dr. Guyatt says, and several committees have adopted variations of a middle-ground approach. In an approach that he favors, all guideline-formulating panelists are conflict-free but begin their work by meeting with a separate group of experts who may have some conflicts but can help point out the main issues. The panelists then deliberate and write a draft of the recommendations, after which they meet again with the experts to receive feedback before finalizing the draft.

In a related approach, experts sit on the panel and discuss the evidence, but those with conflicts recuse themselves before the group votes on any recommendations. Delineating between discussions of the evidence and discussions of recommendations can be tricky, though, increasing the risk that a conflict of interest may influence the outcome. Even so, Dr. Guyatt says the model is still preferable to other alternatives.

Getting the Word Out

Once guidelines have been crafted and vetted, how can hospitalists get up to speed on them? Dr. Feldman’s favorite go-to source is Guideline.gov, a national guideline clearinghouse that he calls one of the best compendiums of available information. Especially helpful, he adds, are details such as how the guidelines were created.

To help maximize his time, he also uses tools like NEJM Journal Watch, which sends daily emails on noteworthy articles and weekend roundups of the most important studies.

“It is a way of at least trying to keep up with what’s going on,” he says. Similarly, he adds, ACP Journal Club provides summaries of important new articles, The Hospitalist can help highlight important guidelines that affect HM, and CME meetings or online modules like SHMconsults.com can help doctors keep pace.

For the past decade, Dr. Guyatt has worked with another popular tool, a guideline-disseminating service called UpToDate. Many alternatives exist, such as DynaMed Plus.

“I think you just need to pick away,” Dr. Feldman says. “You need to decide that as a physician, as a lifelong learner, that you are going to do something that is going to keep you up-to-date. There are many ways of doing it. You just have to decide what you’re going to do and commit to it.”

Researchers are helping out by studying how to present new guidelines in ways that engage doctors and improve patient outcomes. Another trend is to make guidelines routinely accessible not only in electronic medical records but also on tablets and smartphones. Lisa Shieh, MD, PhD, FHM, a hospitalist and clinical professor of medicine at Stanford University Medical Center, has studied how best-practice alerts, or BPAs, impact adherence to guidelines covering the appropriate use of blood products. Dr. Shieh, who splits her time between quality improvement and hospital medicine, says getting new information and guidelines into clinicians’ hands can be a logistical challenge.

“At Stanford, we had a huge official campaign around the guidelines, and that did make some impact, but it wasn’t huge in improving appropriate blood use,” she says. When the medial center set up a BPA through the electronic medical record system, however, both overall and inappropriate blood use declined significantly. In fact, the percentage of providers ordering blood products for patients with a hemoglobin count above 8 g/dL dropped from 60% to 25%.6

One difference maker, Dr. Shieh says, was providing education at the moment a doctor actually ordered blood. To avoid alert fatigue, the “smart BPA” fires only if a doctor tries to order blood and the patient’s hemoglobin is greater than 7 or 8 g/dL, depending on the diagnosis. If the doctor still wants to transfuse, the system requests a clinical indication for the exception.

Despite the clear improvement in appropriate use, the team wanted to understand why 25% of providers were still ordering blood products for patients with a hemoglobin count greater than 8 despite the triggered BPA and whether additional interventions could yield further improvements. Through their study, the researchers documented several reasons for the continued ordering. In some cases, the system failed to properly document actual or potential bleeding as an indicator. In other cases, the ordering reflected a lack of consensus on the guidelines in fields like hematology and oncology.

One of the most intriguing reasons, though, was that residents often did the ordering at the behest of an attending who might have never seen the BPA.

“It’s not actually reaching the audience making the decision; it might be reaching the audience that’s just carrying out the order,” Dr. Shieh says.

The insight, she says, may provide an opportunity to talk with attending physicians who may not have completely bought into the guidelines and to involve the entire team in the decision-making process.

Hospitalists, she says, can play a vital role in guideline development and implementation, especially for strategies that include BPAs.

“I think they’re the perfect group to help use this technology wisely because they are at the front lines taking care of patients so they’ll know the best workflow of when these alerts fire and maybe which ones happen the most often,” Dr. Shieh says. “I think this is a fantastic opportunity to get more hospitalists involved in designing these alerts and collaborating with the IT folks.”

Even with widespread buy-in from providers, guidelines may not reach their full potential without a careful consideration of patients’ values and concerns. Experts say joint deliberations and discussions are especially important for guidelines that are complicated, controversial, or carrying potential risks that must be weighed against the benefits.

Some of the conversations are easy, with well-defined risks and benefits and clear patient preferences, but others must traverse vast tracts of gray area. Fortunately, Dr. Feldman says, more tools also are becoming available for this kind of shared decision making. Some use pictorial representations to help patients understand the potential outcomes of alternative courses of action or inaction.

“Sometimes, that pictorial representation is worth the 1,000 words that we wouldn’t be able to adequately describe otherwise,” he says.

Similarly, Cincinnati Children’s has developed tools to help to ease the shared decision-making process.

“We look where there’s equivocal evidence or no evidence and have developed tools that help the clinician have that conversation with the family and then have them informed enough that they can actually weigh in on what they want,” Gerhardt says. One end product is a card or trifold pamphlet that might help parents understand the benefits and side effects of alternate strategies.

“Typically, in medicine, we’re used to telling people what needs to be done,” she says. “So shared decision making is kind of a different thing for clinicians to engage in.” TH

Bryn Nelson, PhD, is a freelance writer in Seattle.

References

1. Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Physicians’ lack of adherence to National Heart, Lung, and Blood Institute guidelines for pediatric lipid screening. Clin Pediatr. 2015;54(12):1200-1205.
2. Maynard G, Jenkins IH, Merli GJ. Venous thromboembolism prevention guidelines for medical inpatients: mind the (implementation) gap. J Hosp Med. 2013;8(10):582-588.
3. Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Circulation. 2015;131(11):980-987.
4. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726-735.
6. 6. Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med. 2015;10(1):1-7.

One recent paper in Clinical Pediatrics, for example, chronicled low adherence to the 2011 National Heart, Lung, and Blood Institute lipid screening guidelines in primary-care settings.1 Another cautioned providers to “mind the (implementation) gap” in venous thromboembolism prevention guidelines for medical inpatients.2 A third found that lower adherence to guidelines issued by the American College of Cardiology/American Heart Association for acute coronary syndrome patients was significantly associated with higher bleeding and mortality rates.3

Both clinical trials and real-world studies have demonstrated that when guidelines are applied, patients do better, says William Lewis, MD, professor of medicine at Case Western Reserve University and director of the Heart & Vascular Center at MetroHealth in Cleveland. So why aren’t they followed more consistently?

Experts in both HM and other disciplines cite multiple obstacles. Lack of evidence, conflicting evidence, or lack of awareness about evidence can all conspire against the main goal of helping providers deliver consistent high-value care, says Christopher Moriates, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

“In our day-to-day lives as hospitalists, for the vast majority probably of what we do there’s no clear guideline or there’s a guideline that doesn’t necessarily apply to the patient standing in front of me,” he says.

Even when a guideline is clear and relevant, other doctors say inadequate dissemination and implementation can still derail quality improvement efforts.

“A lot of what we do as physicians is what we learned in residency, and to incorporate the new data is difficult,” says Leonard Feldman, MD, SFHM, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore.

Dr. Feldman believes many doctors have yet to integrate recently revised hypertension and cholesterol guidelines into their practice, for example. Some guidelines have proven more complex or controversial, limiting their adoption.

“I know I struggle to keep up with all of the guidelines, and I’m in a big academic center where people are talking about them all the time, and I’m working with residents who are talking about them all the time,” Dr. Feldman says.

Despite the remaining gaps, however, many researchers agree that momentum has built steadily over the past two decades toward a more systematic approach to creating solid evidence-based guidelines and integrating them into real-world decision making.

Emphasis on Evidence and Transparency

The term “evidence-based medicine” was coined in 1990 by Gordon Guyatt, MD, MSc, FRCPC, distinguished professor of medicine and clinical epidemiology at McMaster University in Hamilton, Ontario. It’s played an active role in formulating guidelines for multiple organizations. The guideline-writing process, Dr. Guyatt says, once consisted of little more than self-selected clinicians sitting around a table.

“It used to be that a bunch of experts got together and decided and made the recommendations with very little in the way of a systematic process and certainly not evidence based,” he says.

Cincinnati Children’s Hospital Medical Center was among the pioneers pushing for a more systematic approach; the hospital began working on its own guidelines in 1995 and published the first of many the following year.

“We started evidence-based guidelines when the docs were still saying, ‘This is cookbook medicine. I don’t know if I want to do this or not,’” says Wendy Gerhardt, MSN, director of evidence-based decision making in the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s.

Some doctors also argued that clinical guidelines would stifle innovation, cramp their individual style, or intrude on their relationships with patients. Despite some lingering misgivings among clinicians, however, the process has gained considerable support. In 2000, an organization called the GRADE Working Group (Grading of Recommendations, Assessment, Development and Evaluation) began developing a new approach to raise the quality of evidence and strength of recommendations.

The group’s work led to a 2004 article in BMJ, and the journal subsequently published a six-part series about GRADE for clinicians.4 More recently, the Journal of Clinical Epidemiology also delved into the issue with a 15-part series detailing the GRADE methodology.5 Together, Dr. Guyatt says, the articles have become a go-to guide for guidelines and have helped solidify the focus on evidence.

Cincinnati Children’s and other institutions also have developed tools, and the Institute of Medicine has published guideline-writing standards.

“So it’s easier than it’s ever been to know whether or not you have a decent guideline in your hand,” Gerhardt says.

Likewise, medical organizations are more clearly explaining how they came up with different kinds of guidelines. Evidence-based and consensus guidelines aren’t necessarily mutually exclusive, though consensus building is often used in the absence of high-quality evidence. Some organizations have limited the pool of evidence for guidelines to randomized controlled trial data.

“Unfortunately, for us in the real world, we actually have to make decisions even when there’s not enough data,” Dr. Feldman says.

Sometimes, the best available evidence may be observational studies, and some committees still try to reach a consensus based on that evidence and on the panelists’ professional opinions.

Dr. Guyatt agrees that it’s “absolutely not” true that evidence-based guidelines require randomized controlled trials. “What you need for any recommendation is a thorough review and summary of the best available evidence,” he says.

As part of each final document, Cincinnati Children’s details how it created the guideline, when the literature searches occurred, how the committee reached a consensus, and which panelists participated in the deliberations. The information, Gerhardt says, allows anyone else to “make some sensible decisions about whether or not it’s a guideline you want to use.”

Guideline-crafting institutions are also focusing more on the proper makeup of their panels. In general, Dr. Guyatt says, a panel with more than 10 people can be unwieldy. Guidelines that include many specific recommendations, however, may require multiple subsections, each with its own committee.

Dr. Guyatt is careful to note that, like many other experts, he has multiple potential conflicts of interest, such as working on the anti-thrombotic guidelines issued by the American College of Chest Physicians. Committees, he says, have become increasingly aware of how properly handling conflicts (financial or otherwise) can be critical in building and maintaining trust among clinicians and patients. One technique is to ensure that a diversity of opinions is reflected among a committee whose experts have various conflicts. If one expert’s company makes drug A, for example, then the committee also includes experts involved with drugs B or C. As an alternative, some committees have explicitly barred anyone with a conflict of interest from participating at all.

But experts often provide crucial input, Dr. Guyatt says, and several committees have adopted variations of a middle-ground approach. In an approach that he favors, all guideline-formulating panelists are conflict-free but begin their work by meeting with a separate group of experts who may have some conflicts but can help point out the main issues. The panelists then deliberate and write a draft of the recommendations, after which they meet again with the experts to receive feedback before finalizing the draft.

In a related approach, experts sit on the panel and discuss the evidence, but those with conflicts recuse themselves before the group votes on any recommendations. Delineating between discussions of the evidence and discussions of recommendations can be tricky, though, increasing the risk that a conflict of interest may influence the outcome. Even so, Dr. Guyatt says the model is still preferable to other alternatives.

Getting the Word Out

Once guidelines have been crafted and vetted, how can hospitalists get up to speed on them? Dr. Feldman’s favorite go-to source is Guideline.gov, a national guideline clearinghouse that he calls one of the best compendiums of available information. Especially helpful, he adds, are details such as how the guidelines were created.

To help maximize his time, he also uses tools like NEJM Journal Watch, which sends daily emails on noteworthy articles and weekend roundups of the most important studies.

“It is a way of at least trying to keep up with what’s going on,” he says. Similarly, he adds, ACP Journal Club provides summaries of important new articles, The Hospitalist can help highlight important guidelines that affect HM, and CME meetings or online modules like SHMconsults.com can help doctors keep pace.

For the past decade, Dr. Guyatt has worked with another popular tool, a guideline-disseminating service called UpToDate. Many alternatives exist, such as DynaMed Plus.

“I think you just need to pick away,” Dr. Feldman says. “You need to decide that as a physician, as a lifelong learner, that you are going to do something that is going to keep you up-to-date. There are many ways of doing it. You just have to decide what you’re going to do and commit to it.”

Researchers are helping out by studying how to present new guidelines in ways that engage doctors and improve patient outcomes. Another trend is to make guidelines routinely accessible not only in electronic medical records but also on tablets and smartphones. Lisa Shieh, MD, PhD, FHM, a hospitalist and clinical professor of medicine at Stanford University Medical Center, has studied how best-practice alerts, or BPAs, impact adherence to guidelines covering the appropriate use of blood products. Dr. Shieh, who splits her time between quality improvement and hospital medicine, says getting new information and guidelines into clinicians’ hands can be a logistical challenge.

“At Stanford, we had a huge official campaign around the guidelines, and that did make some impact, but it wasn’t huge in improving appropriate blood use,” she says. When the medial center set up a BPA through the electronic medical record system, however, both overall and inappropriate blood use declined significantly. In fact, the percentage of providers ordering blood products for patients with a hemoglobin count above 8 g/dL dropped from 60% to 25%.6

One difference maker, Dr. Shieh says, was providing education at the moment a doctor actually ordered blood. To avoid alert fatigue, the “smart BPA” fires only if a doctor tries to order blood and the patient’s hemoglobin is greater than 7 or 8 g/dL, depending on the diagnosis. If the doctor still wants to transfuse, the system requests a clinical indication for the exception.

Despite the clear improvement in appropriate use, the team wanted to understand why 25% of providers were still ordering blood products for patients with a hemoglobin count greater than 8 despite the triggered BPA and whether additional interventions could yield further improvements. Through their study, the researchers documented several reasons for the continued ordering. In some cases, the system failed to properly document actual or potential bleeding as an indicator. In other cases, the ordering reflected a lack of consensus on the guidelines in fields like hematology and oncology.

One of the most intriguing reasons, though, was that residents often did the ordering at the behest of an attending who might have never seen the BPA.

“It’s not actually reaching the audience making the decision; it might be reaching the audience that’s just carrying out the order,” Dr. Shieh says.

The insight, she says, may provide an opportunity to talk with attending physicians who may not have completely bought into the guidelines and to involve the entire team in the decision-making process.

Hospitalists, she says, can play a vital role in guideline development and implementation, especially for strategies that include BPAs.

“I think they’re the perfect group to help use this technology wisely because they are at the front lines taking care of patients so they’ll know the best workflow of when these alerts fire and maybe which ones happen the most often,” Dr. Shieh says. “I think this is a fantastic opportunity to get more hospitalists involved in designing these alerts and collaborating with the IT folks.”

Even with widespread buy-in from providers, guidelines may not reach their full potential without a careful consideration of patients’ values and concerns. Experts say joint deliberations and discussions are especially important for guidelines that are complicated, controversial, or carrying potential risks that must be weighed against the benefits.

Some of the conversations are easy, with well-defined risks and benefits and clear patient preferences, but others must traverse vast tracts of gray area. Fortunately, Dr. Feldman says, more tools also are becoming available for this kind of shared decision making. Some use pictorial representations to help patients understand the potential outcomes of alternative courses of action or inaction.

“Sometimes, that pictorial representation is worth the 1,000 words that we wouldn’t be able to adequately describe otherwise,” he says.

Similarly, Cincinnati Children’s has developed tools to help to ease the shared decision-making process.

“We look where there’s equivocal evidence or no evidence and have developed tools that help the clinician have that conversation with the family and then have them informed enough that they can actually weigh in on what they want,” Gerhardt says. One end product is a card or trifold pamphlet that might help parents understand the benefits and side effects of alternate strategies.

“Typically, in medicine, we’re used to telling people what needs to be done,” she says. “So shared decision making is kind of a different thing for clinicians to engage in.” TH

Bryn Nelson, PhD, is a freelance writer in Seattle.

References

1. Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Physicians’ lack of adherence to National Heart, Lung, and Blood Institute guidelines for pediatric lipid screening. Clin Pediatr. 2015;54(12):1200-1205.
2. Maynard G, Jenkins IH, Merli GJ. Venous thromboembolism prevention guidelines for medical inpatients: mind the (implementation) gap. J Hosp Med. 2013;8(10):582-588.
3. Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Circulation. 2015;131(11):980-987.
4. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726-735.
6. 6. Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med. 2015;10(1):1-7.

[WpProQuiz 15] [WpProQuiz_toplist 15]

[WpProQuiz 15] [WpProQuiz_toplist 15]

[WpProQuiz 15] [WpProQuiz_toplist 15]

The Centers for Medicare & Medicaid Services (CMS) has too many new payment models for a practicing doctor to keep up with them all. But there are three that I think are most important for hospitalists to know something about: hospital value-based purchasing, MACRA-related models, and bundled payments. Here, I’ll focus on the latter, which unlike the first two, influences payment to both hospitals and physicians (as well as other providers).

Bundles for Different Diagnoses

Bundled payment programs are the most visible of CMS’s episode payment models (EPMs). There are currently voluntary bundle models (called Bundled Payments for Care Improvement, or BPCI) across many different diagnoses. And in some locales, there is a mandatory bundle program for hip and knee replacements that began in March 2016 (called Comprehensive Care for Joint Replacement, or CCJR or just CJR).

These programs are set to expand significantly in the next few years. The Surgical Hip and Femur Fracture Treatment (SHFFT) becomes active in 2017 in some locales. It will essentially add hip and femur fractures requiring surgery to the existing CJR program. New bundles for acute myocardial infarction, either managed medically or with percutaneous coronary intervention (PCI), and coronary bypass surgery will become mandatory in some parts of the country beginning July 2017.

How the Programs Work

CMS totals all Medicare dollars paid per patient historically for the relevant bundle. This includes payments to the hospital (e.g., the DRG payment) and all fees paid to physicians, therapists, visiting nurses, skilled nursing facilities, etc., from the time of hospital admission through 90 days after discharge. It then sets a target spend (or price) for that diagnosis that is about 3% below the historical average. Because it is based on the past track record of a hospital and its market (or region), the price will vary from place to place.

If, going forward, the Medicare spend for each patient is below the target, CMS pays that amount to the hospital. But if the spend is above the target, the hospital pays some or all of that amount to CMS. Presumably, hospitals will have negotiated with others, such as physicians, how such an “upside” or penalty payment will be divided between them.

It’s worth noting that all parties continue to bill, and are paid by Medicare, via the same fee-for-service arrangements currently in place. It is only at the time of a “true up” that an upside is paid or penalty assessed. And hospitals are eligible for upside payments only if they perform above a threshold on a few quality and patient satisfaction metrics.

The details of these programs are incredibly complicated, and I’m intentionally providing a very simple description of them here. I think that nearly all practicing clinicians should not try to learn and keep up with all of the precise details. They change often! Instead, it’s best to focus on the big picture only and rely on others at the hospital to keep track of the details.

Ways to Lower the Spend

These programs are intended to provide a significant financial incentive to find lower-cost ways to care for patients while still ensuring good care. Any successful effort to lower the cost should start by analyzing just what Medicare spends on each element of care over the more than 90 days each patient is in the bundle. For example, for hip and knee replacement patients, nearly half of the spend goes toward post-hospital services such as a skilled nursing facility and home nursing visits. So the best opportunity to reduce the spend may be to reduce utilization of these services where appropriate.

For patients in the bundles for coronary artery bypass grafting and acute myocardial infarction treated with PCI, only about 10% of the total spend goes to post-hospital services. For these, it might be more effective to focus cost reductions on other things.

Each organization will need to make its own decisions regarding where to focus cost-reduction efforts across the bundle. For many of us, that will mean moving away from a focus on traditional hospitalist-related cost-containment efforts like length of stay or pharmacy costs and instead looking at the bigger picture, including use of post-hospital services.

Some Things to Watch

I expect there will be a number of side effects of these payment models that hospitalists will care about. Doctors in different specialties, for example, might change their minds about whether they want to serve as attending physicians for “bundle patients.” One scenario is that if orthopedists have an opportunity to realize a significant financial upside, they may prefer to serve as attendings for hip fracture patients rather than leaving to hospitalists financially important decisions such as whether patients are discharged to a skilled nursing facility or home. We’ll just have to see how that plays out and be prepared to advocate for our position if different from other specialties.

Successful performance in bundles requires effective coordination of care across settings, and I’m hopeful this will benefit patients. Hospitals and skilled nursing facilities, for example, will need to work together more effectively to curb unnecessary days in the facilities and to reduce readmissions. Many hospitals have already begun developing a preferred network of skilled nursing facilities for referrals that is based on demonstrating good care and low returns to the hospital. Your hospital has probably already started doing this work even if you haven’t heard about it yet.

For me, one of the most concerning outcomes of bundles is the negotiations between providers regarding how an upside or penalty is to be shared among them. I suspect this won’t be contentious initially, but as the dollars at stake grow, it could lead to increasingly stressful negotiations and relationships.

And, lastly, like any payment model, bundles are “gameable,” especially bundles for medical diagnoses such as congestive heart failure or pneumonia, which can be gamed by lowering the threshold for admitting less-sick patients to inpatient status. The spend for these patients, who are less likely to require expensive post-hospital services or be readmitted, will lower the average spend in the bundle, increasing the chance of an upside payment for the providers. TH

The Centers for Medicare & Medicaid Services (CMS) has too many new payment models for a practicing doctor to keep up with them all. But there are three that I think are most important for hospitalists to know something about: hospital value-based purchasing, MACRA-related models, and bundled payments. Here, I’ll focus on the latter, which unlike the first two, influences payment to both hospitals and physicians (as well as other providers).

Bundles for Different Diagnoses

Bundled payment programs are the most visible of CMS’s episode payment models (EPMs). There are currently voluntary bundle models (called Bundled Payments for Care Improvement, or BPCI) across many different diagnoses. And in some locales, there is a mandatory bundle program for hip and knee replacements that began in March 2016 (called Comprehensive Care for Joint Replacement, or CCJR or just CJR).

These programs are set to expand significantly in the next few years. The Surgical Hip and Femur Fracture Treatment (SHFFT) becomes active in 2017 in some locales. It will essentially add hip and femur fractures requiring surgery to the existing CJR program. New bundles for acute myocardial infarction, either managed medically or with percutaneous coronary intervention (PCI), and coronary bypass surgery will become mandatory in some parts of the country beginning July 2017.

How the Programs Work

CMS totals all Medicare dollars paid per patient historically for the relevant bundle. This includes payments to the hospital (e.g., the DRG payment) and all fees paid to physicians, therapists, visiting nurses, skilled nursing facilities, etc., from the time of hospital admission through 90 days after discharge. It then sets a target spend (or price) for that diagnosis that is about 3% below the historical average. Because it is based on the past track record of a hospital and its market (or region), the price will vary from place to place.

If, going forward, the Medicare spend for each patient is below the target, CMS pays that amount to the hospital. But if the spend is above the target, the hospital pays some or all of that amount to CMS. Presumably, hospitals will have negotiated with others, such as physicians, how such an “upside” or penalty payment will be divided between them.

It’s worth noting that all parties continue to bill, and are paid by Medicare, via the same fee-for-service arrangements currently in place. It is only at the time of a “true up” that an upside is paid or penalty assessed. And hospitals are eligible for upside payments only if they perform above a threshold on a few quality and patient satisfaction metrics.

The details of these programs are incredibly complicated, and I’m intentionally providing a very simple description of them here. I think that nearly all practicing clinicians should not try to learn and keep up with all of the precise details. They change often! Instead, it’s best to focus on the big picture only and rely on others at the hospital to keep track of the details.

Ways to Lower the Spend

These programs are intended to provide a significant financial incentive to find lower-cost ways to care for patients while still ensuring good care. Any successful effort to lower the cost should start by analyzing just what Medicare spends on each element of care over the more than 90 days each patient is in the bundle. For example, for hip and knee replacement patients, nearly half of the spend goes toward post-hospital services such as a skilled nursing facility and home nursing visits. So the best opportunity to reduce the spend may be to reduce utilization of these services where appropriate.

For patients in the bundles for coronary artery bypass grafting and acute myocardial infarction treated with PCI, only about 10% of the total spend goes to post-hospital services. For these, it might be more effective to focus cost reductions on other things.

Each organization will need to make its own decisions regarding where to focus cost-reduction efforts across the bundle. For many of us, that will mean moving away from a focus on traditional hospitalist-related cost-containment efforts like length of stay or pharmacy costs and instead looking at the bigger picture, including use of post-hospital services.

Some Things to Watch

I expect there will be a number of side effects of these payment models that hospitalists will care about. Doctors in different specialties, for example, might change their minds about whether they want to serve as attending physicians for “bundle patients.” One scenario is that if orthopedists have an opportunity to realize a significant financial upside, they may prefer to serve as attendings for hip fracture patients rather than leaving to hospitalists financially important decisions such as whether patients are discharged to a skilled nursing facility or home. We’ll just have to see how that plays out and be prepared to advocate for our position if different from other specialties.

Successful performance in bundles requires effective coordination of care across settings, and I’m hopeful this will benefit patients. Hospitals and skilled nursing facilities, for example, will need to work together more effectively to curb unnecessary days in the facilities and to reduce readmissions. Many hospitals have already begun developing a preferred network of skilled nursing facilities for referrals that is based on demonstrating good care and low returns to the hospital. Your hospital has probably already started doing this work even if you haven’t heard about it yet.

For me, one of the most concerning outcomes of bundles is the negotiations between providers regarding how an upside or penalty is to be shared among them. I suspect this won’t be contentious initially, but as the dollars at stake grow, it could lead to increasingly stressful negotiations and relationships.

And, lastly, like any payment model, bundles are “gameable,” especially bundles for medical diagnoses such as congestive heart failure or pneumonia, which can be gamed by lowering the threshold for admitting less-sick patients to inpatient status. The spend for these patients, who are less likely to require expensive post-hospital services or be readmitted, will lower the average spend in the bundle, increasing the chance of an upside payment for the providers. TH

The Centers for Medicare & Medicaid Services (CMS) has too many new payment models for a practicing doctor to keep up with them all. But there are three that I think are most important for hospitalists to know something about: hospital value-based purchasing, MACRA-related models, and bundled payments. Here, I’ll focus on the latter, which unlike the first two, influences payment to both hospitals and physicians (as well as other providers).

Bundles for Different Diagnoses

Bundled payment programs are the most visible of CMS’s episode payment models (EPMs). There are currently voluntary bundle models (called Bundled Payments for Care Improvement, or BPCI) across many different diagnoses. And in some locales, there is a mandatory bundle program for hip and knee replacements that began in March 2016 (called Comprehensive Care for Joint Replacement, or CCJR or just CJR).

These programs are set to expand significantly in the next few years. The Surgical Hip and Femur Fracture Treatment (SHFFT) becomes active in 2017 in some locales. It will essentially add hip and femur fractures requiring surgery to the existing CJR program. New bundles for acute myocardial infarction, either managed medically or with percutaneous coronary intervention (PCI), and coronary bypass surgery will become mandatory in some parts of the country beginning July 2017.

How the Programs Work

CMS totals all Medicare dollars paid per patient historically for the relevant bundle. This includes payments to the hospital (e.g., the DRG payment) and all fees paid to physicians, therapists, visiting nurses, skilled nursing facilities, etc., from the time of hospital admission through 90 days after discharge. It then sets a target spend (or price) for that diagnosis that is about 3% below the historical average. Because it is based on the past track record of a hospital and its market (or region), the price will vary from place to place.

If, going forward, the Medicare spend for each patient is below the target, CMS pays that amount to the hospital. But if the spend is above the target, the hospital pays some or all of that amount to CMS. Presumably, hospitals will have negotiated with others, such as physicians, how such an “upside” or penalty payment will be divided between them.

It’s worth noting that all parties continue to bill, and are paid by Medicare, via the same fee-for-service arrangements currently in place. It is only at the time of a “true up” that an upside is paid or penalty assessed. And hospitals are eligible for upside payments only if they perform above a threshold on a few quality and patient satisfaction metrics.

The details of these programs are incredibly complicated, and I’m intentionally providing a very simple description of them here. I think that nearly all practicing clinicians should not try to learn and keep up with all of the precise details. They change often! Instead, it’s best to focus on the big picture only and rely on others at the hospital to keep track of the details.

Ways to Lower the Spend

These programs are intended to provide a significant financial incentive to find lower-cost ways to care for patients while still ensuring good care. Any successful effort to lower the cost should start by analyzing just what Medicare spends on each element of care over the more than 90 days each patient is in the bundle. For example, for hip and knee replacement patients, nearly half of the spend goes toward post-hospital services such as a skilled nursing facility and home nursing visits. So the best opportunity to reduce the spend may be to reduce utilization of these services where appropriate.

For patients in the bundles for coronary artery bypass grafting and acute myocardial infarction treated with PCI, only about 10% of the total spend goes to post-hospital services. For these, it might be more effective to focus cost reductions on other things.

Each organization will need to make its own decisions regarding where to focus cost-reduction efforts across the bundle. For many of us, that will mean moving away from a focus on traditional hospitalist-related cost-containment efforts like length of stay or pharmacy costs and instead looking at the bigger picture, including use of post-hospital services.

Some Things to Watch

I expect there will be a number of side effects of these payment models that hospitalists will care about. Doctors in different specialties, for example, might change their minds about whether they want to serve as attending physicians for “bundle patients.” One scenario is that if orthopedists have an opportunity to realize a significant financial upside, they may prefer to serve as attendings for hip fracture patients rather than leaving to hospitalists financially important decisions such as whether patients are discharged to a skilled nursing facility or home. We’ll just have to see how that plays out and be prepared to advocate for our position if different from other specialties.

Successful performance in bundles requires effective coordination of care across settings, and I’m hopeful this will benefit patients. Hospitals and skilled nursing facilities, for example, will need to work together more effectively to curb unnecessary days in the facilities and to reduce readmissions. Many hospitals have already begun developing a preferred network of skilled nursing facilities for referrals that is based on demonstrating good care and low returns to the hospital. Your hospital has probably already started doing this work even if you haven’t heard about it yet.

For me, one of the most concerning outcomes of bundles is the negotiations between providers regarding how an upside or penalty is to be shared among them. I suspect this won’t be contentious initially, but as the dollars at stake grow, it could lead to increasingly stressful negotiations and relationships.

And, lastly, like any payment model, bundles are “gameable,” especially bundles for medical diagnoses such as congestive heart failure or pneumonia, which can be gamed by lowering the threshold for admitting less-sick patients to inpatient status. The spend for these patients, who are less likely to require expensive post-hospital services or be readmitted, will lower the average spend in the bundle, increasing the chance of an upside payment for the providers. TH

When Rana Tan, MD, was a young child, she often played with dolls, dressing them up and inventing stories about them. Teachers would comment to Dr. Tan’s parents about her creativity and that she belonged on stage or behind the scenes, writing plays or movies. But her parents discouraged any profession relating to the arts, wanting a more respectable career for their daughter.

To some, there is nothing more respectable than medicine. After graduating medical school at the University California, Davis in 1990, Dr. Tan spent the next four years at Mercy Hospital in San Diego, completing a one-year internship, two years of residency, and another year of chief residency. Then from 1994 to 1997, she pursued a pulmonary and critical-care fellowship at the Medical College of Wisconsin.

After training for seven years, Dr. Tan worked in private practice in Bremerton, Wash., practicing pulmonary and critical-care medicine for the next eight years, and then joined Sound Physicians as a hospitalist in 2005 at Harrison Medical Center in Bremerton. Since 2010, she has served as its chief hospitalist.

Despite all of her education and training, Dr. Tan never forgot about her dolls or how much fun she had creating their life stories.

For years, much of her creativity had been bottled up and was ready to be unleashed. But how? The answer sat a few blocks away from Harrison: the Bremerton Community Theater. For the past 17 years, Dr. Tan has volunteered for the theater by performing in numerous plays, creating costumes and set designs, and directing more than a dozen plays for the youth theater program.

“As much as I enjoy my career, I don’t know if I could just do medicine,” says Dr. Tan, adding that acting demands her to explore a wide variety of emotions, which enables her to better understand and connect with her patients. “I’m incredibly fortunate that we have a community theater down the street and am afforded the opportunity to do all sorts of things that keep me balanced.”

Curtains Up

Back in 1999, Dr. Tan auditioned for Come Back to the Five and Dime, Jimmy Dean, Jimmy Dean, a 1976 play by Ed Graczyk about the reunion of childhood friends in drought-stricken Texas.

“This community theater had a very strong clique of people who acted in everything,” she says, adding that the same directors tapped the same actors for various roles. “It was very difficult to break in. I was very lucky that I was cast as Joanne in this play.”

Over the next two years, she repeatedly auditioned for various plays, but she never got so much as a thank you, let alone a callback. It seemed her acting career was over before it even started. But luck was on her side. She received an audition notice from a local director who had not volunteered at the theater for some time and didn’t have a preset agenda for casting.

“I got one of the lead parts in Rumors,” she says, referring to a Neil Simon play. “Then I was cast in more and more plays.”

Of all the roles she has performed, two are most memorable: Kate Keller in Arthur Miller’s All My Sons and Sister Aloysius in John Patrick Shanley’s Doubt: A Parable.

Dr. Tan explains that both roles spoke to her in different ways. Even though she never personally experienced the plights of the characters, she understood them, related to them, and became them on stage.

“I’m very grateful for having these two theater experiences,” she says.

Like many community theaters, Bremerton is staffed by volunteers. Out of necessity, Dr. Tan was asked to help with set design and also costuming. To boost interest in the arts and ticket sales, the theater also established a club for children between ages 6 and 18. It produced one show, but the youth program wasn’t well-organized and soon fizzled. Simultaneously, Dr. Tan wrote an adaption of Little Red Riding Hood, which revived the program and was chosen for the summer play in 2007.

Since then, she has directed 15 more plays, including Sleeping Beauty, The Little Mermaid, and A Seussified Christmas Carol. She says her favorite, however, was a spoof on the Law & Order television show called Law & Order: Fairy Tale Unit.

Confidence and Coyotes

Each play at the community theater may involve up to 50 cast members, including children.

“We have children who are incredibly shy, you can’t hear them on stage, and they run to sit next to their parents,” she says. “Sometimes, by the end of the audition process, their voices are stronger and they’re more confident because we audition in groups. By the end of the rehearsal process, they’re not clinging to their parents anymore.”

As a director, she has never yelled or raised her voice to any child actor. When she needs children to be quiet to listen to her rules or instructions, she uses a hand signal called “Quiet Coyote.” (Touch your thumb to your third and fourth fingers and raise your index finger and pinkie to resemble a coyote’s head.) She says they immediately stop talking and start listening.

One of her favorite youth theater memories happened several years ago, when one parent said that her six-year-old daughter wanted to dress up as Dr. Tan for Halloween by styling her hair in a bun, wearing glasses, and carrying a clipboard.

“Even though I may be exhausted at the end of the day, I still head straight to the theater,” Dr. Tan says, adding that her husband, Eric Spencer, a professional actor, is the theater’s technical director.

“Every heaviness that I have on my shoulders from the hospital is now gone. It resets me and puts me in a different place. For that, I will always be grateful.” TH

Carol Patton is a freelance writer in Las Vegas.

When Rana Tan, MD, was a young child, she often played with dolls, dressing them up and inventing stories about them. Teachers would comment to Dr. Tan’s parents about her creativity and that she belonged on stage or behind the scenes, writing plays or movies. But her parents discouraged any profession relating to the arts, wanting a more respectable career for their daughter.

To some, there is nothing more respectable than medicine. After graduating medical school at the University California, Davis in 1990, Dr. Tan spent the next four years at Mercy Hospital in San Diego, completing a one-year internship, two years of residency, and another year of chief residency. Then from 1994 to 1997, she pursued a pulmonary and critical-care fellowship at the Medical College of Wisconsin.

After training for seven years, Dr. Tan worked in private practice in Bremerton, Wash., practicing pulmonary and critical-care medicine for the next eight years, and then joined Sound Physicians as a hospitalist in 2005 at Harrison Medical Center in Bremerton. Since 2010, she has served as its chief hospitalist.

Despite all of her education and training, Dr. Tan never forgot about her dolls or how much fun she had creating their life stories.

For years, much of her creativity had been bottled up and was ready to be unleashed. But how? The answer sat a few blocks away from Harrison: the Bremerton Community Theater. For the past 17 years, Dr. Tan has volunteered for the theater by performing in numerous plays, creating costumes and set designs, and directing more than a dozen plays for the youth theater program.

“As much as I enjoy my career, I don’t know if I could just do medicine,” says Dr. Tan, adding that acting demands her to explore a wide variety of emotions, which enables her to better understand and connect with her patients. “I’m incredibly fortunate that we have a community theater down the street and am afforded the opportunity to do all sorts of things that keep me balanced.”

Curtains Up

Back in 1999, Dr. Tan auditioned for Come Back to the Five and Dime, Jimmy Dean, Jimmy Dean, a 1976 play by Ed Graczyk about the reunion of childhood friends in drought-stricken Texas.

“This community theater had a very strong clique of people who acted in everything,” she says, adding that the same directors tapped the same actors for various roles. “It was very difficult to break in. I was very lucky that I was cast as Joanne in this play.”

Over the next two years, she repeatedly auditioned for various plays, but she never got so much as a thank you, let alone a callback. It seemed her acting career was over before it even started. But luck was on her side. She received an audition notice from a local director who had not volunteered at the theater for some time and didn’t have a preset agenda for casting.

“I got one of the lead parts in Rumors,” she says, referring to a Neil Simon play. “Then I was cast in more and more plays.”

Of all the roles she has performed, two are most memorable: Kate Keller in Arthur Miller’s All My Sons and Sister Aloysius in John Patrick Shanley’s Doubt: A Parable.

Dr. Tan explains that both roles spoke to her in different ways. Even though she never personally experienced the plights of the characters, she understood them, related to them, and became them on stage.

“I’m very grateful for having these two theater experiences,” she says.

Like many community theaters, Bremerton is staffed by volunteers. Out of necessity, Dr. Tan was asked to help with set design and also costuming. To boost interest in the arts and ticket sales, the theater also established a club for children between ages 6 and 18. It produced one show, but the youth program wasn’t well-organized and soon fizzled. Simultaneously, Dr. Tan wrote an adaption of Little Red Riding Hood, which revived the program and was chosen for the summer play in 2007.

Since then, she has directed 15 more plays, including Sleeping Beauty, The Little Mermaid, and A Seussified Christmas Carol. She says her favorite, however, was a spoof on the Law & Order television show called Law & Order: Fairy Tale Unit.

Confidence and Coyotes

Each play at the community theater may involve up to 50 cast members, including children.

“We have children who are incredibly shy, you can’t hear them on stage, and they run to sit next to their parents,” she says. “Sometimes, by the end of the audition process, their voices are stronger and they’re more confident because we audition in groups. By the end of the rehearsal process, they’re not clinging to their parents anymore.”

As a director, she has never yelled or raised her voice to any child actor. When she needs children to be quiet to listen to her rules or instructions, she uses a hand signal called “Quiet Coyote.” (Touch your thumb to your third and fourth fingers and raise your index finger and pinkie to resemble a coyote’s head.) She says they immediately stop talking and start listening.

One of her favorite youth theater memories happened several years ago, when one parent said that her six-year-old daughter wanted to dress up as Dr. Tan for Halloween by styling her hair in a bun, wearing glasses, and carrying a clipboard.

“Even though I may be exhausted at the end of the day, I still head straight to the theater,” Dr. Tan says, adding that her husband, Eric Spencer, a professional actor, is the theater’s technical director.

“Every heaviness that I have on my shoulders from the hospital is now gone. It resets me and puts me in a different place. For that, I will always be grateful.” TH

Carol Patton is a freelance writer in Las Vegas.

When Rana Tan, MD, was a young child, she often played with dolls, dressing them up and inventing stories about them. Teachers would comment to Dr. Tan’s parents about her creativity and that she belonged on stage or behind the scenes, writing plays or movies. But her parents discouraged any profession relating to the arts, wanting a more respectable career for their daughter.

To some, there is nothing more respectable than medicine. After graduating medical school at the University California, Davis in 1990, Dr. Tan spent the next four years at Mercy Hospital in San Diego, completing a one-year internship, two years of residency, and another year of chief residency. Then from 1994 to 1997, she pursued a pulmonary and critical-care fellowship at the Medical College of Wisconsin.

After training for seven years, Dr. Tan worked in private practice in Bremerton, Wash., practicing pulmonary and critical-care medicine for the next eight years, and then joined Sound Physicians as a hospitalist in 2005 at Harrison Medical Center in Bremerton. Since 2010, she has served as its chief hospitalist.

Despite all of her education and training, Dr. Tan never forgot about her dolls or how much fun she had creating their life stories.

For years, much of her creativity had been bottled up and was ready to be unleashed. But how? The answer sat a few blocks away from Harrison: the Bremerton Community Theater. For the past 17 years, Dr. Tan has volunteered for the theater by performing in numerous plays, creating costumes and set designs, and directing more than a dozen plays for the youth theater program.

“As much as I enjoy my career, I don’t know if I could just do medicine,” says Dr. Tan, adding that acting demands her to explore a wide variety of emotions, which enables her to better understand and connect with her patients. “I’m incredibly fortunate that we have a community theater down the street and am afforded the opportunity to do all sorts of things that keep me balanced.”

Curtains Up

Back in 1999, Dr. Tan auditioned for Come Back to the Five and Dime, Jimmy Dean, Jimmy Dean, a 1976 play by Ed Graczyk about the reunion of childhood friends in drought-stricken Texas.

“This community theater had a very strong clique of people who acted in everything,” she says, adding that the same directors tapped the same actors for various roles. “It was very difficult to break in. I was very lucky that I was cast as Joanne in this play.”

Over the next two years, she repeatedly auditioned for various plays, but she never got so much as a thank you, let alone a callback. It seemed her acting career was over before it even started. But luck was on her side. She received an audition notice from a local director who had not volunteered at the theater for some time and didn’t have a preset agenda for casting.

“I got one of the lead parts in Rumors,” she says, referring to a Neil Simon play. “Then I was cast in more and more plays.”

Of all the roles she has performed, two are most memorable: Kate Keller in Arthur Miller’s All My Sons and Sister Aloysius in John Patrick Shanley’s Doubt: A Parable.

Dr. Tan explains that both roles spoke to her in different ways. Even though she never personally experienced the plights of the characters, she understood them, related to them, and became them on stage.

“I’m very grateful for having these two theater experiences,” she says.

Like many community theaters, Bremerton is staffed by volunteers. Out of necessity, Dr. Tan was asked to help with set design and also costuming. To boost interest in the arts and ticket sales, the theater also established a club for children between ages 6 and 18. It produced one show, but the youth program wasn’t well-organized and soon fizzled. Simultaneously, Dr. Tan wrote an adaption of Little Red Riding Hood, which revived the program and was chosen for the summer play in 2007.

Since then, she has directed 15 more plays, including Sleeping Beauty, The Little Mermaid, and A Seussified Christmas Carol. She says her favorite, however, was a spoof on the Law & Order television show called Law & Order: Fairy Tale Unit.

Confidence and Coyotes

Each play at the community theater may involve up to 50 cast members, including children.

“We have children who are incredibly shy, you can’t hear them on stage, and they run to sit next to their parents,” she says. “Sometimes, by the end of the audition process, their voices are stronger and they’re more confident because we audition in groups. By the end of the rehearsal process, they’re not clinging to their parents anymore.”

As a director, she has never yelled or raised her voice to any child actor. When she needs children to be quiet to listen to her rules or instructions, she uses a hand signal called “Quiet Coyote.” (Touch your thumb to your third and fourth fingers and raise your index finger and pinkie to resemble a coyote’s head.) She says they immediately stop talking and start listening.

One of her favorite youth theater memories happened several years ago, when one parent said that her six-year-old daughter wanted to dress up as Dr. Tan for Halloween by styling her hair in a bun, wearing glasses, and carrying a clipboard.

“Even though I may be exhausted at the end of the day, I still head straight to the theater,” Dr. Tan says, adding that her husband, Eric Spencer, a professional actor, is the theater’s technical director.

“Every heaviness that I have on my shoulders from the hospital is now gone. It resets me and puts me in a different place. For that, I will always be grateful.” TH

Carol Patton is a freelance writer in Las Vegas.

I almost quit my job during my third year as a hospitalist. When I began my first hospitalist job out of residency, I was going to be “just a doctor” forever. After all, being at the bedside, holding my patients’ hands, making them feel better one by one was the reason I went into medicine.

Fast-forward three years. I was now a mom and still “just a doctor,” still holding my patients’ hands. Yet, somehow, it was just not enough. I pondered for a year, at times pessimistically, about my hospitalist future: the endless overnight shifts, the weekends away from family, the “spent” feeling after seven days on service. I needed to do something else. I, and many other hospitalist colleagues, went through this phase. I call this “the three-year itch.”

Fast-forward some more, I am a little better at knowing why the three-year itch occurred. For a lifelong hospitalist, it is a major milestone. It is the moment when you realize you are in love with the field of hospital medicine, want to continue for a long time, but also have this scary revelation that you cannot sustain the current status. I suppose this milestone is a natural occurrence, hardwired in our hospitalist-innovator, hospitalist-writer, hospitalist-mom, hospitalist–IT guy, hospitalist–palliative care physician, hospitalist–soon-to-be chief medical officer mind. While hospitalist groups attempt to improve job satisfaction and sustainability by hiring more nocturnists, increasing compensation, designing flexible schedules for moms, etc., I argue that, for many of us, mentoring is paramount in maintaining job satisfaction and sustainability.

Mentoring Essential

Early-career hospitalist mentoring is essential during the first three years of practice as it ensures a smooth transition and assimilation into hospital medicine. While I was surrounded by accomplished hospitalists early in my career, I never realized how essential it was for me to establish a connection with one of them until I was “attacked” by the itch. What exactly does the three-year itch involve? A Hinami et al study plotted job fit against years in current practice. An inflection point at two years of practice became apparent. These first two years, called the “assimilation period,” are when “rapid learning and attrition took place.” Perhaps some of the observed phenomenon are to be expected and unavoidable. However, providing mentorship resources during this vulnerable period would potentially decrease attrition.

I did not quit my job, but I knew I needed to find direction for myself. I spent countless hours on emails, meetings, and, yes, moping around about my future. I wished so often back then that I had a mentor to guide me. My lack of mentorship was not unique. In a survey of 222 pediatric hospitalists, only 44% said they have “adequate mentorship in their careers.”

For more than a year, I was asking the wrong question: What makes a career in hospital medicine satisfying? The Society of Hospital Medicine Career Satisfaction Task Force paper delineated 13 factors, including optimal workload, substantial pay, control over personal time, and collegiality with other physicians, that contribute to job satisfaction for hospitalists. While there are common trends, factors that affect job satisfaction are highly variable across practice models. How do you reconcile the weight of at least 13 factors that contribute to your happiness at work? Having a mentor to brainstorm ideas about job satisfaction for me would have focused my energy productively early on and, more important, could have led to more career satisfaction.

Finding a Mentor

Finding a mentor takes a lot hard work. It takes boldness, creativity, perseverance, and a bit of luck. My quest to find a mentor started at the hospital’s cafeteria with senior hospitalists. It then led me to a few meetings in the C-suite and the chiefs’ offices. I asked MDs, nurses, and quality officers the same question: “How did you get to where you are?” I emailed everyone and met with many. I suppose I was bold (and some may say ambitious), but for me, it was out of necessity. I was pleasantly surprised at the time generously given to me. The willingness to listen was bestowed even by random strangers whom I had never met. I remember very well the day I decided to email the most “famous” hospitalists in the Boston area. I heard back from all except one. I ended up having coffee on a crisp winter morning at a famous hospitalist’s house in the Boston suburbs. I almost trucked in the textbook she had written for an autograph! My path also led me to an hour-and-a-half conversation in a light-filled office in downtown Boston. Leaving at 6:30 p.m., I remember being giddy. I did not find a mentor that very specific day, but I found direction and purpose, which are what I had been looking for.

Sometimes you just have to do it yourself—build your own mentorship program from scratch. I did it at my own institution. There is a paucity of literature on this subject matter. This problem intensifies manyfold for community hospitals like mine. I was never sure of the right way to start a program. Do I start by identifying senior faculty mentors for the group, providing a list of available mentors for interested hospitalists to choose from, or creating a peer mentor network? I was certain though that doing something, even if not as well from the onset, was an improvement. This is where luck matters: I am lucky to be practicing among the most intelligent, ambitious, like-minded colleagues. We have different priorities, and each of us is blazing a separate career path. Yet I sense that we have one thing in common: We are energized and want productive careers in hospital medicine.

Starting a new program also requires leadership support. I fortunately have had unrelenting support at my hospital. Support from leadership comes in various forms: funds set aside for administrative support, assistance in networking to identify potential mentors, expertise (such as in writing and publishing), feedback on the proposed program structure. At the end of the day though, sometimes you just need to start.

While experienced mentors are desperately needed for academic hospitalist groups, a bigger need for mentors exists at community hospitals like mine compared to academic hospitals. Community hospital programs are typically smaller and more recently established, and hence, the pool of experienced and senior hospitalists typically is limited. In tertiary-care settings, mentors are needed to ensure scholarly productivity and promotion, while mentors are needed in community hospitals to ensure career satisfaction and job sustainability. Two years ago, I conducted a professional development survey of my colleagues. Of the 20 hospitalists (70% response rate) who responded, 19 (95%) answered yes to the question, “Are you professionally satisfied with your current hospitalist job?” This tracks well with the 92% of pediatric hospitalists who reported that they are “pleased with their work.” Yet burnout rate was reported to be 29.9% in 20119 and 52.3% more recently.

Why is there such a discrepancy? I think one of the clues lies in the fact that 85% of my colleagues are thinking of pursuing an interest in addition to practicing clinical hospital medicine in the next 10 years. I want to be clear that my fellow hospitalists and I are not looking to leave clinical medicine. We love it. Most of us envision our professional lives in clinical medicine. Yet we need to fulfill our “diastoles.” We also believe in the intertwined nature of a hospitalist’s life and that of a quality officer, a palliative care physician, a billing and compliance officer, etc. We know that as hospitalists, we are well-positioned to improve the care of our patients even when we are not at the bedside. As community hospital hospitalists, we are the grass-roots hospitalists with tremendous potential to impact the care of patients and the future of hospital medicine. We, as much as academic hospitalists, need a mentoring hand for our professional development.

I am “itching” now, six years after finishing residency. There are many days where the “What now?” phrase echoes in my head. Yet with the mentors who I have found, I know that I will have ready listeners when the restless voice gets loud. What troubles me is that many of the 44,000 hospitalists nationwide are suffering through the restlessness without mentors to guide them. The current call to bolster mentorship resources at academic centers, while important, is not enough. Attention, discussion, research, and definitely resources should be allocated to the development of mentorship programs for community hospitals like mine. Of course, I am interested in academic promotions, grants, and FTE support, but the journey of finding mentorship has been most significant in that it led me back my core value: I still want to be “just a doctor” forever. I just know a little more about what type of doctor I want to be. Mentorship is vital to our professional development, job satisfaction, and sustainability as community hospitalists.

References

1. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB. Person-job fit: an exploratory cross-sectional analysis of hospitalists. J Hosp Med. 2013;8(2):96-101.
2. Pane LA, Davis AB, Ottolini MC. Career satisfaction and the role of mentorship: a survey of pediatric hospitalists. Hosp Pediatr. 2012;2(3):141-148.
3. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB; Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. J Hosp Med. 2012;7(5):402-410.
4. Howell E, Kravet S, Kisuule F, Wright SM. An innovative approach to supporting hospitalist physicians towards academic success. J Hosp Med. 2008;3(4):314-318.
5. Tietjen P, Griner PF. Mentoring of physicians at a community-based health system: preliminary findings. J Hosp Med. 2013;8(11):642-643.
6. Varkey P, Jatoi A, Williams A, et al. The positive impact of a facilitated peer mentoring program on academic skills of women faculty. BMC Med Educ. 2012;12:14.
7. Johnson KS, Hastings SN, Purser JL, Whitson HE. The Junior Faculty Laboratory: an innovative model of peer mentoring. Acad Med. 2011;86(12):1577-1582.
8. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. 2012;27(1):23-27.
9. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
10. Roberts DL, Shanafelt TD, Dyrbye LN, West CP. A national comparison of burnout and work-life balance among internal medicine hospitalists and outpatient general internists. J Hosp Med. 2014;9(3):176-181.
11. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for "diastole": advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

I almost quit my job during my third year as a hospitalist. When I began my first hospitalist job out of residency, I was going to be “just a doctor” forever. After all, being at the bedside, holding my patients’ hands, making them feel better one by one was the reason I went into medicine.

Fast-forward three years. I was now a mom and still “just a doctor,” still holding my patients’ hands. Yet, somehow, it was just not enough. I pondered for a year, at times pessimistically, about my hospitalist future: the endless overnight shifts, the weekends away from family, the “spent” feeling after seven days on service. I needed to do something else. I, and many other hospitalist colleagues, went through this phase. I call this “the three-year itch.”

Fast-forward some more, I am a little better at knowing why the three-year itch occurred. For a lifelong hospitalist, it is a major milestone. It is the moment when you realize you are in love with the field of hospital medicine, want to continue for a long time, but also have this scary revelation that you cannot sustain the current status. I suppose this milestone is a natural occurrence, hardwired in our hospitalist-innovator, hospitalist-writer, hospitalist-mom, hospitalist–IT guy, hospitalist–palliative care physician, hospitalist–soon-to-be chief medical officer mind. While hospitalist groups attempt to improve job satisfaction and sustainability by hiring more nocturnists, increasing compensation, designing flexible schedules for moms, etc., I argue that, for many of us, mentoring is paramount in maintaining job satisfaction and sustainability.

Mentoring Essential

Early-career hospitalist mentoring is essential during the first three years of practice as it ensures a smooth transition and assimilation into hospital medicine. While I was surrounded by accomplished hospitalists early in my career, I never realized how essential it was for me to establish a connection with one of them until I was “attacked” by the itch. What exactly does the three-year itch involve? A Hinami et al study plotted job fit against years in current practice. An inflection point at two years of practice became apparent. These first two years, called the “assimilation period,” are when “rapid learning and attrition took place.” Perhaps some of the observed phenomenon are to be expected and unavoidable. However, providing mentorship resources during this vulnerable period would potentially decrease attrition.

I did not quit my job, but I knew I needed to find direction for myself. I spent countless hours on emails, meetings, and, yes, moping around about my future. I wished so often back then that I had a mentor to guide me. My lack of mentorship was not unique. In a survey of 222 pediatric hospitalists, only 44% said they have “adequate mentorship in their careers.”

For more than a year, I was asking the wrong question: What makes a career in hospital medicine satisfying? The Society of Hospital Medicine Career Satisfaction Task Force paper delineated 13 factors, including optimal workload, substantial pay, control over personal time, and collegiality with other physicians, that contribute to job satisfaction for hospitalists. While there are common trends, factors that affect job satisfaction are highly variable across practice models. How do you reconcile the weight of at least 13 factors that contribute to your happiness at work? Having a mentor to brainstorm ideas about job satisfaction for me would have focused my energy productively early on and, more important, could have led to more career satisfaction.

Finding a Mentor

Finding a mentor takes a lot hard work. It takes boldness, creativity, perseverance, and a bit of luck. My quest to find a mentor started at the hospital’s cafeteria with senior hospitalists. It then led me to a few meetings in the C-suite and the chiefs’ offices. I asked MDs, nurses, and quality officers the same question: “How did you get to where you are?” I emailed everyone and met with many. I suppose I was bold (and some may say ambitious), but for me, it was out of necessity. I was pleasantly surprised at the time generously given to me. The willingness to listen was bestowed even by random strangers whom I had never met. I remember very well the day I decided to email the most “famous” hospitalists in the Boston area. I heard back from all except one. I ended up having coffee on a crisp winter morning at a famous hospitalist’s house in the Boston suburbs. I almost trucked in the textbook she had written for an autograph! My path also led me to an hour-and-a-half conversation in a light-filled office in downtown Boston. Leaving at 6:30 p.m., I remember being giddy. I did not find a mentor that very specific day, but I found direction and purpose, which are what I had been looking for.

Sometimes you just have to do it yourself—build your own mentorship program from scratch. I did it at my own institution. There is a paucity of literature on this subject matter. This problem intensifies manyfold for community hospitals like mine. I was never sure of the right way to start a program. Do I start by identifying senior faculty mentors for the group, providing a list of available mentors for interested hospitalists to choose from, or creating a peer mentor network? I was certain though that doing something, even if not as well from the onset, was an improvement. This is where luck matters: I am lucky to be practicing among the most intelligent, ambitious, like-minded colleagues. We have different priorities, and each of us is blazing a separate career path. Yet I sense that we have one thing in common: We are energized and want productive careers in hospital medicine.

Starting a new program also requires leadership support. I fortunately have had unrelenting support at my hospital. Support from leadership comes in various forms: funds set aside for administrative support, assistance in networking to identify potential mentors, expertise (such as in writing and publishing), feedback on the proposed program structure. At the end of the day though, sometimes you just need to start.

While experienced mentors are desperately needed for academic hospitalist groups, a bigger need for mentors exists at community hospitals like mine compared to academic hospitals. Community hospital programs are typically smaller and more recently established, and hence, the pool of experienced and senior hospitalists typically is limited. In tertiary-care settings, mentors are needed to ensure scholarly productivity and promotion, while mentors are needed in community hospitals to ensure career satisfaction and job sustainability. Two years ago, I conducted a professional development survey of my colleagues. Of the 20 hospitalists (70% response rate) who responded, 19 (95%) answered yes to the question, “Are you professionally satisfied with your current hospitalist job?” This tracks well with the 92% of pediatric hospitalists who reported that they are “pleased with their work.” Yet burnout rate was reported to be 29.9% in 20119 and 52.3% more recently.

Why is there such a discrepancy? I think one of the clues lies in the fact that 85% of my colleagues are thinking of pursuing an interest in addition to practicing clinical hospital medicine in the next 10 years. I want to be clear that my fellow hospitalists and I are not looking to leave clinical medicine. We love it. Most of us envision our professional lives in clinical medicine. Yet we need to fulfill our “diastoles.” We also believe in the intertwined nature of a hospitalist’s life and that of a quality officer, a palliative care physician, a billing and compliance officer, etc. We know that as hospitalists, we are well-positioned to improve the care of our patients even when we are not at the bedside. As community hospital hospitalists, we are the grass-roots hospitalists with tremendous potential to impact the care of patients and the future of hospital medicine. We, as much as academic hospitalists, need a mentoring hand for our professional development.

I am “itching” now, six years after finishing residency. There are many days where the “What now?” phrase echoes in my head. Yet with the mentors who I have found, I know that I will have ready listeners when the restless voice gets loud. What troubles me is that many of the 44,000 hospitalists nationwide are suffering through the restlessness without mentors to guide them. The current call to bolster mentorship resources at academic centers, while important, is not enough. Attention, discussion, research, and definitely resources should be allocated to the development of mentorship programs for community hospitals like mine. Of course, I am interested in academic promotions, grants, and FTE support, but the journey of finding mentorship has been most significant in that it led me back my core value: I still want to be “just a doctor” forever. I just know a little more about what type of doctor I want to be. Mentorship is vital to our professional development, job satisfaction, and sustainability as community hospitalists.

References

1. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB. Person-job fit: an exploratory cross-sectional analysis of hospitalists. J Hosp Med. 2013;8(2):96-101.
2. Pane LA, Davis AB, Ottolini MC. Career satisfaction and the role of mentorship: a survey of pediatric hospitalists. Hosp Pediatr. 2012;2(3):141-148.
3. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB; Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. J Hosp Med. 2012;7(5):402-410.
4. Howell E, Kravet S, Kisuule F, Wright SM. An innovative approach to supporting hospitalist physicians towards academic success. J Hosp Med. 2008;3(4):314-318.
5. Tietjen P, Griner PF. Mentoring of physicians at a community-based health system: preliminary findings. J Hosp Med. 2013;8(11):642-643.
6. Varkey P, Jatoi A, Williams A, et al. The positive impact of a facilitated peer mentoring program on academic skills of women faculty. BMC Med Educ. 2012;12:14.
7. Johnson KS, Hastings SN, Purser JL, Whitson HE. The Junior Faculty Laboratory: an innovative model of peer mentoring. Acad Med. 2011;86(12):1577-1582.
8. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. 2012;27(1):23-27.
9. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
10. Roberts DL, Shanafelt TD, Dyrbye LN, West CP. A national comparison of burnout and work-life balance among internal medicine hospitalists and outpatient general internists. J Hosp Med. 2014;9(3):176-181.
11. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for "diastole": advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

I almost quit my job during my third year as a hospitalist. When I began my first hospitalist job out of residency, I was going to be “just a doctor” forever. After all, being at the bedside, holding my patients’ hands, making them feel better one by one was the reason I went into medicine.

Fast-forward three years. I was now a mom and still “just a doctor,” still holding my patients’ hands. Yet, somehow, it was just not enough. I pondered for a year, at times pessimistically, about my hospitalist future: the endless overnight shifts, the weekends away from family, the “spent” feeling after seven days on service. I needed to do something else. I, and many other hospitalist colleagues, went through this phase. I call this “the three-year itch.”

Fast-forward some more, I am a little better at knowing why the three-year itch occurred. For a lifelong hospitalist, it is a major milestone. It is the moment when you realize you are in love with the field of hospital medicine, want to continue for a long time, but also have this scary revelation that you cannot sustain the current status. I suppose this milestone is a natural occurrence, hardwired in our hospitalist-innovator, hospitalist-writer, hospitalist-mom, hospitalist–IT guy, hospitalist–palliative care physician, hospitalist–soon-to-be chief medical officer mind. While hospitalist groups attempt to improve job satisfaction and sustainability by hiring more nocturnists, increasing compensation, designing flexible schedules for moms, etc., I argue that, for many of us, mentoring is paramount in maintaining job satisfaction and sustainability.

Mentoring Essential

Early-career hospitalist mentoring is essential during the first three years of practice as it ensures a smooth transition and assimilation into hospital medicine. While I was surrounded by accomplished hospitalists early in my career, I never realized how essential it was for me to establish a connection with one of them until I was “attacked” by the itch. What exactly does the three-year itch involve? A Hinami et al study plotted job fit against years in current practice. An inflection point at two years of practice became apparent. These first two years, called the “assimilation period,” are when “rapid learning and attrition took place.” Perhaps some of the observed phenomenon are to be expected and unavoidable. However, providing mentorship resources during this vulnerable period would potentially decrease attrition.

I did not quit my job, but I knew I needed to find direction for myself. I spent countless hours on emails, meetings, and, yes, moping around about my future. I wished so often back then that I had a mentor to guide me. My lack of mentorship was not unique. In a survey of 222 pediatric hospitalists, only 44% said they have “adequate mentorship in their careers.”

For more than a year, I was asking the wrong question: What makes a career in hospital medicine satisfying? The Society of Hospital Medicine Career Satisfaction Task Force paper delineated 13 factors, including optimal workload, substantial pay, control over personal time, and collegiality with other physicians, that contribute to job satisfaction for hospitalists. While there are common trends, factors that affect job satisfaction are highly variable across practice models. How do you reconcile the weight of at least 13 factors that contribute to your happiness at work? Having a mentor to brainstorm ideas about job satisfaction for me would have focused my energy productively early on and, more important, could have led to more career satisfaction.

Finding a Mentor

Finding a mentor takes a lot hard work. It takes boldness, creativity, perseverance, and a bit of luck. My quest to find a mentor started at the hospital’s cafeteria with senior hospitalists. It then led me to a few meetings in the C-suite and the chiefs’ offices. I asked MDs, nurses, and quality officers the same question: “How did you get to where you are?” I emailed everyone and met with many. I suppose I was bold (and some may say ambitious), but for me, it was out of necessity. I was pleasantly surprised at the time generously given to me. The willingness to listen was bestowed even by random strangers whom I had never met. I remember very well the day I decided to email the most “famous” hospitalists in the Boston area. I heard back from all except one. I ended up having coffee on a crisp winter morning at a famous hospitalist’s house in the Boston suburbs. I almost trucked in the textbook she had written for an autograph! My path also led me to an hour-and-a-half conversation in a light-filled office in downtown Boston. Leaving at 6:30 p.m., I remember being giddy. I did not find a mentor that very specific day, but I found direction and purpose, which are what I had been looking for.

Sometimes you just have to do it yourself—build your own mentorship program from scratch. I did it at my own institution. There is a paucity of literature on this subject matter. This problem intensifies manyfold for community hospitals like mine. I was never sure of the right way to start a program. Do I start by identifying senior faculty mentors for the group, providing a list of available mentors for interested hospitalists to choose from, or creating a peer mentor network? I was certain though that doing something, even if not as well from the onset, was an improvement. This is where luck matters: I am lucky to be practicing among the most intelligent, ambitious, like-minded colleagues. We have different priorities, and each of us is blazing a separate career path. Yet I sense that we have one thing in common: We are energized and want productive careers in hospital medicine.

Starting a new program also requires leadership support. I fortunately have had unrelenting support at my hospital. Support from leadership comes in various forms: funds set aside for administrative support, assistance in networking to identify potential mentors, expertise (such as in writing and publishing), feedback on the proposed program structure. At the end of the day though, sometimes you just need to start.

While experienced mentors are desperately needed for academic hospitalist groups, a bigger need for mentors exists at community hospitals like mine compared to academic hospitals. Community hospital programs are typically smaller and more recently established, and hence, the pool of experienced and senior hospitalists typically is limited. In tertiary-care settings, mentors are needed to ensure scholarly productivity and promotion, while mentors are needed in community hospitals to ensure career satisfaction and job sustainability. Two years ago, I conducted a professional development survey of my colleagues. Of the 20 hospitalists (70% response rate) who responded, 19 (95%) answered yes to the question, “Are you professionally satisfied with your current hospitalist job?” This tracks well with the 92% of pediatric hospitalists who reported that they are “pleased with their work.” Yet burnout rate was reported to be 29.9% in 20119 and 52.3% more recently.

Why is there such a discrepancy? I think one of the clues lies in the fact that 85% of my colleagues are thinking of pursuing an interest in addition to practicing clinical hospital medicine in the next 10 years. I want to be clear that my fellow hospitalists and I are not looking to leave clinical medicine. We love it. Most of us envision our professional lives in clinical medicine. Yet we need to fulfill our “diastoles.” We also believe in the intertwined nature of a hospitalist’s life and that of a quality officer, a palliative care physician, a billing and compliance officer, etc. We know that as hospitalists, we are well-positioned to improve the care of our patients even when we are not at the bedside. As community hospital hospitalists, we are the grass-roots hospitalists with tremendous potential to impact the care of patients and the future of hospital medicine. We, as much as academic hospitalists, need a mentoring hand for our professional development.

I am “itching” now, six years after finishing residency. There are many days where the “What now?” phrase echoes in my head. Yet with the mentors who I have found, I know that I will have ready listeners when the restless voice gets loud. What troubles me is that many of the 44,000 hospitalists nationwide are suffering through the restlessness without mentors to guide them. The current call to bolster mentorship resources at academic centers, while important, is not enough. Attention, discussion, research, and definitely resources should be allocated to the development of mentorship programs for community hospitals like mine. Of course, I am interested in academic promotions, grants, and FTE support, but the journey of finding mentorship has been most significant in that it led me back my core value: I still want to be “just a doctor” forever. I just know a little more about what type of doctor I want to be. Mentorship is vital to our professional development, job satisfaction, and sustainability as community hospitalists.

References

1. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB. Person-job fit: an exploratory cross-sectional analysis of hospitalists. J Hosp Med. 2013;8(2):96-101.
2. Pane LA, Davis AB, Ottolini MC. Career satisfaction and the role of mentorship: a survey of pediatric hospitalists. Hosp Pediatr. 2012;2(3):141-148.
3. Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB; Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. J Hosp Med. 2012;7(5):402-410.
4. Howell E, Kravet S, Kisuule F, Wright SM. An innovative approach to supporting hospitalist physicians towards academic success. J Hosp Med. 2008;3(4):314-318.
5. Tietjen P, Griner PF. Mentoring of physicians at a community-based health system: preliminary findings. J Hosp Med. 2013;8(11):642-643.
6. Varkey P, Jatoi A, Williams A, et al. The positive impact of a facilitated peer mentoring program on academic skills of women faculty. BMC Med Educ. 2012;12:14.
7. Johnson KS, Hastings SN, Purser JL, Whitson HE. The Junior Faculty Laboratory: an innovative model of peer mentoring. Acad Med. 2011;86(12):1577-1582.
8. Reid MB, Misky GJ, Harrison RA, Sharpe B, Auerbach A, Glasheen JJ. Mentorship, productivity, and promotion among academic hospitalists. J Gen Intern Med. 2012;27(1):23-27.
9. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
10. Roberts DL, Shanafelt TD, Dyrbye LN, West CP. A national comparison of burnout and work-life balance among internal medicine hospitalists and outpatient general internists. J Hosp Med. 2014;9(3):176-181.
11. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for "diastole": advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.