The Hospitalist

In fact, according to the 2015 Palliative Care Report Card from the Center to Advance Palliative Care (CAPC), 67 percent of hospitals with 50 or more beds had a designated palliative care program.1

While core palliative care skills can be performed by frontline clinicians including hospitalists, specialty palliative care consults are the ones who are called in for complicated cases. The Hospitalist asked several palliative care experts for advice on how to clarify definitions, distinctions, and roles. This is what they told us:

Palliative care is not synonymous with end-of-life care.

Palliative care advocates call this the biggest misconception they struggle to overcome, with the potential to inhibit its contributions to patient care in the hospital. Palliative care, they say, is for any patient with a serious illness who is struggling to cope with the fallout from that illness in their lives.

“Our biggest impact can come earlier in the illness,” says Jeanie Youngwerth, MD, director of the University of Colorado Hospital’s Palliative Care Consult Service in Aurora. “We help people do the best they can for as long as they can. If you’re even considering a palliative-care consult, then do it sooner rather than later.”

Palliative care can offer more than just help with difficult conversations, adds Daniel Fischberg, MD, PhD, FAAHPM, medical director of the Pain and Palliative Care Department at The Queen’s Medical Center in Honolulu. For example, the palliative-care team can work with patients to clarify their expectations and goals for care, plan for what comes next, and address troubling symptoms—whether physical or emotional, Dr. Fischberg says.

“We can really help patients and families who are facing unique and challenging needs,” he says.

The experts also say that palliative care is not synonymous with hospice care, which is a comprehensive service that provides specialized terminal care for patients with a prognosis of six months or fewer to live. Both, however, share many of the same principles and techniques of symptom management and psycho-social-spiritual support. But some patients and families may associate a palliative-care referral with hospice care or have other misconceptions and fears about it. Hospitalists are challenged to provide a consistent message clarifying that palliative care can be helpful for seriously ill patients regardless of prognosis or other medical treatments they’re receiving.

“It’s human nature not to want to deal with our mortality, and any word that gets associated with death and dying can turn people off,” says Joseph Rotella, MD, chief medical officer of the American Academy of Hospice and Palliative Medicine (AAHPM). “The best way to prevent this is to define it in terms of patient and family needs: ‘Let’s bring in our comfort specialists.’ Doctors should not apologize when referring to a service that has proven its value. We should be happy to recommend it often and early.”

Patients with serious illness can benefit from palliative care.

CAPC defines palliative care as “specialized medical care for people with serious illnesses.” It focuses on providing patients with relief from the symptoms and stress of a serious illness, regardless of their diagnosis, at any age and at any stage of a serious illness. This service is provided by a specially trained interdisciplinary palliative-care team of doctors, nurses, and other specialists who work together with patients’ other doctors. Their goal is to improve quality of life for both patients and their families with an extra layer of support.

Palliative care is also a medical specialty that involves specialty training, including year-long hospice and palliative medicine (HPM) fellowships now offered at 112 sites accredited by the Accreditation Council for Graduate Medical Education. Subspecialty board certification is also available through 10 collaborating medical specialty boards within the American Board of Medical Specialties as well as by the American Osteopathic Association. Palliative-care programs are now certified by The Joint Commission, with similar recognition under development by the Community Health Accreditation Partner.

Palliative care is intended for patients facing challenges.

Palliative care is intended for patients who might be expected to face stresses and challenges in any area of their lives as a result of serious illness. This may include, for example, patients who experience frequent emergency department visits, hospital readmissions, or prolonged ICU stays, as well as cancer patients who are admitted to the hospital solely to address out-of-control symptoms resulting from their disease and its treatment.

“We can help with the burdens of any challenging symptoms,” Dr. Fischberg says.

Other examples of appropriate palliative-care referrals are when next steps for patients’ treatment are not clear, when there are questions about patients’ real goals of care, and when unmet needs such as unrelieved symptoms have put their families in a state of distress, whether physical, emotional, social, or spiritual. Patients may need guidance about weighing their care options.

Palliative care is also available for children and their families.

The philosophy and organization of palliative care for delivering compassionate care for children with chronic, complex, or life-threatening conditions are much the same as for adults. In 2013, the American Academy of Pediatrics issued a Pediatric Palliative Care and Hospice Care policy statement,2 which outlined core commitments in such areas as respecting and partnering with patients and families and pursuing care that is high-quality, readily accessible, and equitable.

As with adults, a referral for palliative care typically is most helpful for the more complex cases, says Joanne Wolfe, MD, MPH, director of Pediatric Palliative Care at Boston Children’s Hospital. The palliative care team can offer emotional support to the parents of children with complex illnesses and help them understand confusing treatment options. The children, too, need a sounding board.

“If I were teaching a group of hospitalists, I would emphasize foundational principles of palliative care, starting with relationship and understanding patients’ and families’ goals of care,” Dr. Wolfe says. If the family is struggling to cope with the illness and the hospitalist doesn’t have good answers, that’s when to call palliative care, she adds.

Palliative care’s role is not to talk patients and their families out of treatments.

The palliative-care team tries to enter cases without an agenda, Dr. Fischberg says, rather than aiming to get patients to stop treatments or agree to a do-not-resuscitate (DNR) order.

“We’re interested in what the hospitalist thinks about what best care for this patient looks like but also in eliciting the patient’s values and preferences,” he says.

Palliative-care professionals are skilled at delicately communicating bad news and helping patients and families clarify what their goals of care really are, says Robert Crook, MD, FACP, associate medical director of Mount Carmel Hospice and Palliative Care in Columbus, Ohio.

“It’s more about helping to improve communication between the primary-care team and the patient and family—not talking somebody out of something but helping them understand each other better,” Dr. Crook says.

Palliative care can reduce costs of care on average, but it does not achieve this by rationing care or denying treatments.

“We’re not there to cut costs or to get patients discharged sooner or to steer them away from costly treatments,” explains Dr. Rotella. “The last thing a palliative-care team wants is to be viewed as a care rationer. But if the patient understands what’s really going on, they often won’t want treatments that don’t help. So, in that way, we are part of the solution.”

Dr. Rotella calls this cost-effectiveness a side effect of palliative care, when patients are empowered to make decisions about their own care. “That’s where you achieve the triple aim,” he says. “They feel better about it because they are in the driver’s seat. If a patient wants a treatment consistent with their values, we will advocate for it.”

One study found that patients at eight U.S. hospitals who received palliative care incurred significantly lower hospital costs than a matched group receiving usual care, with an average reduction in direct hospital costs of almost $1,700 for patients discharged alive and almost $5,000 per admission for patients who died in the hospital.3 Another study found that early palliative care interventions for cancer patients led to significant improvements in both quality of life and mood compared with patients receiving standard care, with less cost and fewer aggressive treatments at the end of life but longer survival.4

One of the main tools of the palliative care team is the family meeting.

Family meetings are scheduled to allow as many family members as possible to attend, and the primary-care team and relevant specialists typically are also invited. Many palliative-care teams use a standardized format that involves introductions, clarification of each participant’s understanding of the patient’s prognosis, and an effort to reconcile the patient’s hopes and values with medical realities and possibilities, Dr. Fischberg explains.

“That is such a critical component of our care, where we make sure the patient and family are fully informed and foster shared decision making that results in patients being more comfortable with care that better matches what they want,” says Dr. Rotella.

The palliative-care team typically becomes involved via a consultation request from a patient’s attending physician.

“A big part of our job is doing our homework,” Dr. Youngwerth says. “We’ll talk to the team about what’s going on. We want to get as much information as possible about the patient, about prognosis, about the perspectives of people caring for them. Don’t be surprised if the palliative-care team contacts you to get your input on the prognosis and other medical details in order to best inform their discussion with the patient and family.”

Then the palliative-care team will follow consult protocol in reporting back to the primary medical team.

Palliative-care teams can assist busy hospitalists with difficult patient conversations.

“When I’m on the hospitalist service, I’ll pull in the palliative-care team,” Dr. Youngwerth explains. “It’s not that I don’t have the skills; I don’t have the time.”

Conversations aimed at clarifying goals of care can take 90 minutes or more, but the palliative-care team will take as much time as needed to achieve clarification.

It’s important that hospitalists remain involved in these cases, says Christian Sinclair, MD, assistant professor in the division of palliative medicine at the University of Kansas Medical Center in Kansas City and president-elect of AAHPM.

“Just because you have access to palliative-care services, don’t miss the chance to enhance your own communication skills and your ability to address these issues head on,” Dr. Sinclair says.

American Academy of Hospice and Palliative Medicine is a participant in Choosing Wisely.

The Choosing Wisely program, initiated by the American Board of Internal Medicine Foundation, invites medical societies to identify five treatments that should be questioned by physicians and patients based on lack of supporting evidence in the research base. The Society of Hospital Medicine is also a participant in this initiative.

For AAHPM, one of its recommendations was: “Don’t delay palliative care for a patient with serious illness who has a physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment.” Other Choosing Wisely suggestions include not recommending feeding tubes for patients with advanced dementia, not leaving implantable cardioverter defibrillators (ICDs) activated when these are not consistent with patient/family goals of care, and not recommending more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.

Different palliative-care programs provide different services.

It is important for hospitalists to learn their local palliative-care programs and what they emphasize and are able to offer—or not, says Dr. Sinclair.

“There are so many different models,” he says. “Spend some time reaching out to them, outside of actual consults, and find out what their comfort level is on various issues. Hospitalists and palliative-care teams should get to know each other better.”

Access to palliative care and the comprehensiveness of the team and services can vary between hospitals, while access to community-based palliative care outside of the hospital is even more variable.

“Palliative-care teams often have a better sense of our partners in the community and access to community-based palliative care,” Dr. Fischberg says.

References

1. Morrison RS, Meier DE. America’s Care of Serious Illness: 2015 State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. New York, NY: Center to Advance Palliative Care; 2015.
2. American Academy of Pediatrics. Policy statement: pediatric palliative care and hospice care commitments, guidelines, and recommendations. Pediatr. 2013;132(5):966-972.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Temel JS, Greer JA, Muzikansky et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.

In fact, according to the 2015 Palliative Care Report Card from the Center to Advance Palliative Care (CAPC), 67 percent of hospitals with 50 or more beds had a designated palliative care program.1

While core palliative care skills can be performed by frontline clinicians including hospitalists, specialty palliative care consults are the ones who are called in for complicated cases. The Hospitalist asked several palliative care experts for advice on how to clarify definitions, distinctions, and roles. This is what they told us:

Palliative care is not synonymous with end-of-life care.

Palliative care advocates call this the biggest misconception they struggle to overcome, with the potential to inhibit its contributions to patient care in the hospital. Palliative care, they say, is for any patient with a serious illness who is struggling to cope with the fallout from that illness in their lives.

“Our biggest impact can come earlier in the illness,” says Jeanie Youngwerth, MD, director of the University of Colorado Hospital’s Palliative Care Consult Service in Aurora. “We help people do the best they can for as long as they can. If you’re even considering a palliative-care consult, then do it sooner rather than later.”

Palliative care can offer more than just help with difficult conversations, adds Daniel Fischberg, MD, PhD, FAAHPM, medical director of the Pain and Palliative Care Department at The Queen’s Medical Center in Honolulu. For example, the palliative-care team can work with patients to clarify their expectations and goals for care, plan for what comes next, and address troubling symptoms—whether physical or emotional, Dr. Fischberg says.

“We can really help patients and families who are facing unique and challenging needs,” he says.

The experts also say that palliative care is not synonymous with hospice care, which is a comprehensive service that provides specialized terminal care for patients with a prognosis of six months or fewer to live. Both, however, share many of the same principles and techniques of symptom management and psycho-social-spiritual support. But some patients and families may associate a palliative-care referral with hospice care or have other misconceptions and fears about it. Hospitalists are challenged to provide a consistent message clarifying that palliative care can be helpful for seriously ill patients regardless of prognosis or other medical treatments they’re receiving.

“It’s human nature not to want to deal with our mortality, and any word that gets associated with death and dying can turn people off,” says Joseph Rotella, MD, chief medical officer of the American Academy of Hospice and Palliative Medicine (AAHPM). “The best way to prevent this is to define it in terms of patient and family needs: ‘Let’s bring in our comfort specialists.’ Doctors should not apologize when referring to a service that has proven its value. We should be happy to recommend it often and early.”

Patients with serious illness can benefit from palliative care.

CAPC defines palliative care as “specialized medical care for people with serious illnesses.” It focuses on providing patients with relief from the symptoms and stress of a serious illness, regardless of their diagnosis, at any age and at any stage of a serious illness. This service is provided by a specially trained interdisciplinary palliative-care team of doctors, nurses, and other specialists who work together with patients’ other doctors. Their goal is to improve quality of life for both patients and their families with an extra layer of support.

Palliative care is also a medical specialty that involves specialty training, including year-long hospice and palliative medicine (HPM) fellowships now offered at 112 sites accredited by the Accreditation Council for Graduate Medical Education. Subspecialty board certification is also available through 10 collaborating medical specialty boards within the American Board of Medical Specialties as well as by the American Osteopathic Association. Palliative-care programs are now certified by The Joint Commission, with similar recognition under development by the Community Health Accreditation Partner.

Palliative care is intended for patients facing challenges.

Palliative care is intended for patients who might be expected to face stresses and challenges in any area of their lives as a result of serious illness. This may include, for example, patients who experience frequent emergency department visits, hospital readmissions, or prolonged ICU stays, as well as cancer patients who are admitted to the hospital solely to address out-of-control symptoms resulting from their disease and its treatment.

“We can help with the burdens of any challenging symptoms,” Dr. Fischberg says.

Other examples of appropriate palliative-care referrals are when next steps for patients’ treatment are not clear, when there are questions about patients’ real goals of care, and when unmet needs such as unrelieved symptoms have put their families in a state of distress, whether physical, emotional, social, or spiritual. Patients may need guidance about weighing their care options.

Palliative care is also available for children and their families.

The philosophy and organization of palliative care for delivering compassionate care for children with chronic, complex, or life-threatening conditions are much the same as for adults. In 2013, the American Academy of Pediatrics issued a Pediatric Palliative Care and Hospice Care policy statement,2 which outlined core commitments in such areas as respecting and partnering with patients and families and pursuing care that is high-quality, readily accessible, and equitable.

As with adults, a referral for palliative care typically is most helpful for the more complex cases, says Joanne Wolfe, MD, MPH, director of Pediatric Palliative Care at Boston Children’s Hospital. The palliative care team can offer emotional support to the parents of children with complex illnesses and help them understand confusing treatment options. The children, too, need a sounding board.

“If I were teaching a group of hospitalists, I would emphasize foundational principles of palliative care, starting with relationship and understanding patients’ and families’ goals of care,” Dr. Wolfe says. If the family is struggling to cope with the illness and the hospitalist doesn’t have good answers, that’s when to call palliative care, she adds.

Palliative care’s role is not to talk patients and their families out of treatments.

The palliative-care team tries to enter cases without an agenda, Dr. Fischberg says, rather than aiming to get patients to stop treatments or agree to a do-not-resuscitate (DNR) order.

“We’re interested in what the hospitalist thinks about what best care for this patient looks like but also in eliciting the patient’s values and preferences,” he says.

Palliative-care professionals are skilled at delicately communicating bad news and helping patients and families clarify what their goals of care really are, says Robert Crook, MD, FACP, associate medical director of Mount Carmel Hospice and Palliative Care in Columbus, Ohio.

“It’s more about helping to improve communication between the primary-care team and the patient and family—not talking somebody out of something but helping them understand each other better,” Dr. Crook says.

Palliative care can reduce costs of care on average, but it does not achieve this by rationing care or denying treatments.

“We’re not there to cut costs or to get patients discharged sooner or to steer them away from costly treatments,” explains Dr. Rotella. “The last thing a palliative-care team wants is to be viewed as a care rationer. But if the patient understands what’s really going on, they often won’t want treatments that don’t help. So, in that way, we are part of the solution.”

Dr. Rotella calls this cost-effectiveness a side effect of palliative care, when patients are empowered to make decisions about their own care. “That’s where you achieve the triple aim,” he says. “They feel better about it because they are in the driver’s seat. If a patient wants a treatment consistent with their values, we will advocate for it.”

One study found that patients at eight U.S. hospitals who received palliative care incurred significantly lower hospital costs than a matched group receiving usual care, with an average reduction in direct hospital costs of almost $1,700 for patients discharged alive and almost $5,000 per admission for patients who died in the hospital.3 Another study found that early palliative care interventions for cancer patients led to significant improvements in both quality of life and mood compared with patients receiving standard care, with less cost and fewer aggressive treatments at the end of life but longer survival.4

One of the main tools of the palliative care team is the family meeting.

Family meetings are scheduled to allow as many family members as possible to attend, and the primary-care team and relevant specialists typically are also invited. Many palliative-care teams use a standardized format that involves introductions, clarification of each participant’s understanding of the patient’s prognosis, and an effort to reconcile the patient’s hopes and values with medical realities and possibilities, Dr. Fischberg explains.

“That is such a critical component of our care, where we make sure the patient and family are fully informed and foster shared decision making that results in patients being more comfortable with care that better matches what they want,” says Dr. Rotella.

The palliative-care team typically becomes involved via a consultation request from a patient’s attending physician.

“A big part of our job is doing our homework,” Dr. Youngwerth says. “We’ll talk to the team about what’s going on. We want to get as much information as possible about the patient, about prognosis, about the perspectives of people caring for them. Don’t be surprised if the palliative-care team contacts you to get your input on the prognosis and other medical details in order to best inform their discussion with the patient and family.”

Then the palliative-care team will follow consult protocol in reporting back to the primary medical team.

Palliative-care teams can assist busy hospitalists with difficult patient conversations.

“When I’m on the hospitalist service, I’ll pull in the palliative-care team,” Dr. Youngwerth explains. “It’s not that I don’t have the skills; I don’t have the time.”

Conversations aimed at clarifying goals of care can take 90 minutes or more, but the palliative-care team will take as much time as needed to achieve clarification.

It’s important that hospitalists remain involved in these cases, says Christian Sinclair, MD, assistant professor in the division of palliative medicine at the University of Kansas Medical Center in Kansas City and president-elect of AAHPM.

“Just because you have access to palliative-care services, don’t miss the chance to enhance your own communication skills and your ability to address these issues head on,” Dr. Sinclair says.

American Academy of Hospice and Palliative Medicine is a participant in Choosing Wisely.

The Choosing Wisely program, initiated by the American Board of Internal Medicine Foundation, invites medical societies to identify five treatments that should be questioned by physicians and patients based on lack of supporting evidence in the research base. The Society of Hospital Medicine is also a participant in this initiative.

For AAHPM, one of its recommendations was: “Don’t delay palliative care for a patient with serious illness who has a physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment.” Other Choosing Wisely suggestions include not recommending feeding tubes for patients with advanced dementia, not leaving implantable cardioverter defibrillators (ICDs) activated when these are not consistent with patient/family goals of care, and not recommending more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.

Different palliative-care programs provide different services.

It is important for hospitalists to learn their local palliative-care programs and what they emphasize and are able to offer—or not, says Dr. Sinclair.

“There are so many different models,” he says. “Spend some time reaching out to them, outside of actual consults, and find out what their comfort level is on various issues. Hospitalists and palliative-care teams should get to know each other better.”

Access to palliative care and the comprehensiveness of the team and services can vary between hospitals, while access to community-based palliative care outside of the hospital is even more variable.

“Palliative-care teams often have a better sense of our partners in the community and access to community-based palliative care,” Dr. Fischberg says.

References

1. Morrison RS, Meier DE. America’s Care of Serious Illness: 2015 State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. New York, NY: Center to Advance Palliative Care; 2015.
2. American Academy of Pediatrics. Policy statement: pediatric palliative care and hospice care commitments, guidelines, and recommendations. Pediatr. 2013;132(5):966-972.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Temel JS, Greer JA, Muzikansky et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.

In fact, according to the 2015 Palliative Care Report Card from the Center to Advance Palliative Care (CAPC), 67 percent of hospitals with 50 or more beds had a designated palliative care program.1

While core palliative care skills can be performed by frontline clinicians including hospitalists, specialty palliative care consults are the ones who are called in for complicated cases. The Hospitalist asked several palliative care experts for advice on how to clarify definitions, distinctions, and roles. This is what they told us:

Palliative care is not synonymous with end-of-life care.

Palliative care advocates call this the biggest misconception they struggle to overcome, with the potential to inhibit its contributions to patient care in the hospital. Palliative care, they say, is for any patient with a serious illness who is struggling to cope with the fallout from that illness in their lives.

“Our biggest impact can come earlier in the illness,” says Jeanie Youngwerth, MD, director of the University of Colorado Hospital’s Palliative Care Consult Service in Aurora. “We help people do the best they can for as long as they can. If you’re even considering a palliative-care consult, then do it sooner rather than later.”

Palliative care can offer more than just help with difficult conversations, adds Daniel Fischberg, MD, PhD, FAAHPM, medical director of the Pain and Palliative Care Department at The Queen’s Medical Center in Honolulu. For example, the palliative-care team can work with patients to clarify their expectations and goals for care, plan for what comes next, and address troubling symptoms—whether physical or emotional, Dr. Fischberg says.

“We can really help patients and families who are facing unique and challenging needs,” he says.

The experts also say that palliative care is not synonymous with hospice care, which is a comprehensive service that provides specialized terminal care for patients with a prognosis of six months or fewer to live. Both, however, share many of the same principles and techniques of symptom management and psycho-social-spiritual support. But some patients and families may associate a palliative-care referral with hospice care or have other misconceptions and fears about it. Hospitalists are challenged to provide a consistent message clarifying that palliative care can be helpful for seriously ill patients regardless of prognosis or other medical treatments they’re receiving.

“It’s human nature not to want to deal with our mortality, and any word that gets associated with death and dying can turn people off,” says Joseph Rotella, MD, chief medical officer of the American Academy of Hospice and Palliative Medicine (AAHPM). “The best way to prevent this is to define it in terms of patient and family needs: ‘Let’s bring in our comfort specialists.’ Doctors should not apologize when referring to a service that has proven its value. We should be happy to recommend it often and early.”

Patients with serious illness can benefit from palliative care.

CAPC defines palliative care as “specialized medical care for people with serious illnesses.” It focuses on providing patients with relief from the symptoms and stress of a serious illness, regardless of their diagnosis, at any age and at any stage of a serious illness. This service is provided by a specially trained interdisciplinary palliative-care team of doctors, nurses, and other specialists who work together with patients’ other doctors. Their goal is to improve quality of life for both patients and their families with an extra layer of support.

Palliative care is also a medical specialty that involves specialty training, including year-long hospice and palliative medicine (HPM) fellowships now offered at 112 sites accredited by the Accreditation Council for Graduate Medical Education. Subspecialty board certification is also available through 10 collaborating medical specialty boards within the American Board of Medical Specialties as well as by the American Osteopathic Association. Palliative-care programs are now certified by The Joint Commission, with similar recognition under development by the Community Health Accreditation Partner.

Palliative care is intended for patients facing challenges.

Palliative care is intended for patients who might be expected to face stresses and challenges in any area of their lives as a result of serious illness. This may include, for example, patients who experience frequent emergency department visits, hospital readmissions, or prolonged ICU stays, as well as cancer patients who are admitted to the hospital solely to address out-of-control symptoms resulting from their disease and its treatment.

“We can help with the burdens of any challenging symptoms,” Dr. Fischberg says.

Other examples of appropriate palliative-care referrals are when next steps for patients’ treatment are not clear, when there are questions about patients’ real goals of care, and when unmet needs such as unrelieved symptoms have put their families in a state of distress, whether physical, emotional, social, or spiritual. Patients may need guidance about weighing their care options.

Palliative care is also available for children and their families.

The philosophy and organization of palliative care for delivering compassionate care for children with chronic, complex, or life-threatening conditions are much the same as for adults. In 2013, the American Academy of Pediatrics issued a Pediatric Palliative Care and Hospice Care policy statement,2 which outlined core commitments in such areas as respecting and partnering with patients and families and pursuing care that is high-quality, readily accessible, and equitable.

As with adults, a referral for palliative care typically is most helpful for the more complex cases, says Joanne Wolfe, MD, MPH, director of Pediatric Palliative Care at Boston Children’s Hospital. The palliative care team can offer emotional support to the parents of children with complex illnesses and help them understand confusing treatment options. The children, too, need a sounding board.

“If I were teaching a group of hospitalists, I would emphasize foundational principles of palliative care, starting with relationship and understanding patients’ and families’ goals of care,” Dr. Wolfe says. If the family is struggling to cope with the illness and the hospitalist doesn’t have good answers, that’s when to call palliative care, she adds.

Palliative care’s role is not to talk patients and their families out of treatments.

The palliative-care team tries to enter cases without an agenda, Dr. Fischberg says, rather than aiming to get patients to stop treatments or agree to a do-not-resuscitate (DNR) order.

“We’re interested in what the hospitalist thinks about what best care for this patient looks like but also in eliciting the patient’s values and preferences,” he says.

Palliative-care professionals are skilled at delicately communicating bad news and helping patients and families clarify what their goals of care really are, says Robert Crook, MD, FACP, associate medical director of Mount Carmel Hospice and Palliative Care in Columbus, Ohio.

“It’s more about helping to improve communication between the primary-care team and the patient and family—not talking somebody out of something but helping them understand each other better,” Dr. Crook says.

Palliative care can reduce costs of care on average, but it does not achieve this by rationing care or denying treatments.

“We’re not there to cut costs or to get patients discharged sooner or to steer them away from costly treatments,” explains Dr. Rotella. “The last thing a palliative-care team wants is to be viewed as a care rationer. But if the patient understands what’s really going on, they often won’t want treatments that don’t help. So, in that way, we are part of the solution.”

Dr. Rotella calls this cost-effectiveness a side effect of palliative care, when patients are empowered to make decisions about their own care. “That’s where you achieve the triple aim,” he says. “They feel better about it because they are in the driver’s seat. If a patient wants a treatment consistent with their values, we will advocate for it.”

One study found that patients at eight U.S. hospitals who received palliative care incurred significantly lower hospital costs than a matched group receiving usual care, with an average reduction in direct hospital costs of almost $1,700 for patients discharged alive and almost $5,000 per admission for patients who died in the hospital.3 Another study found that early palliative care interventions for cancer patients led to significant improvements in both quality of life and mood compared with patients receiving standard care, with less cost and fewer aggressive treatments at the end of life but longer survival.4

One of the main tools of the palliative care team is the family meeting.

Family meetings are scheduled to allow as many family members as possible to attend, and the primary-care team and relevant specialists typically are also invited. Many palliative-care teams use a standardized format that involves introductions, clarification of each participant’s understanding of the patient’s prognosis, and an effort to reconcile the patient’s hopes and values with medical realities and possibilities, Dr. Fischberg explains.

“That is such a critical component of our care, where we make sure the patient and family are fully informed and foster shared decision making that results in patients being more comfortable with care that better matches what they want,” says Dr. Rotella.

The palliative-care team typically becomes involved via a consultation request from a patient’s attending physician.

“A big part of our job is doing our homework,” Dr. Youngwerth says. “We’ll talk to the team about what’s going on. We want to get as much information as possible about the patient, about prognosis, about the perspectives of people caring for them. Don’t be surprised if the palliative-care team contacts you to get your input on the prognosis and other medical details in order to best inform their discussion with the patient and family.”

Then the palliative-care team will follow consult protocol in reporting back to the primary medical team.

Palliative-care teams can assist busy hospitalists with difficult patient conversations.

“When I’m on the hospitalist service, I’ll pull in the palliative-care team,” Dr. Youngwerth explains. “It’s not that I don’t have the skills; I don’t have the time.”

Conversations aimed at clarifying goals of care can take 90 minutes or more, but the palliative-care team will take as much time as needed to achieve clarification.

It’s important that hospitalists remain involved in these cases, says Christian Sinclair, MD, assistant professor in the division of palliative medicine at the University of Kansas Medical Center in Kansas City and president-elect of AAHPM.

“Just because you have access to palliative-care services, don’t miss the chance to enhance your own communication skills and your ability to address these issues head on,” Dr. Sinclair says.

American Academy of Hospice and Palliative Medicine is a participant in Choosing Wisely.

The Choosing Wisely program, initiated by the American Board of Internal Medicine Foundation, invites medical societies to identify five treatments that should be questioned by physicians and patients based on lack of supporting evidence in the research base. The Society of Hospital Medicine is also a participant in this initiative.

For AAHPM, one of its recommendations was: “Don’t delay palliative care for a patient with serious illness who has a physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment.” Other Choosing Wisely suggestions include not recommending feeding tubes for patients with advanced dementia, not leaving implantable cardioverter defibrillators (ICDs) activated when these are not consistent with patient/family goals of care, and not recommending more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.

Different palliative-care programs provide different services.

It is important for hospitalists to learn their local palliative-care programs and what they emphasize and are able to offer—or not, says Dr. Sinclair.

“There are so many different models,” he says. “Spend some time reaching out to them, outside of actual consults, and find out what their comfort level is on various issues. Hospitalists and palliative-care teams should get to know each other better.”

Access to palliative care and the comprehensiveness of the team and services can vary between hospitals, while access to community-based palliative care outside of the hospital is even more variable.

“Palliative-care teams often have a better sense of our partners in the community and access to community-based palliative care,” Dr. Fischberg says.

References

1. Morrison RS, Meier DE. America’s Care of Serious Illness: 2015 State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. New York, NY: Center to Advance Palliative Care; 2015.
2. American Academy of Pediatrics. Policy statement: pediatric palliative care and hospice care commitments, guidelines, and recommendations. Pediatr. 2013;132(5):966-972.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Temel JS, Greer JA, Muzikansky et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.

Editor's Note: Listen to Robert Blendon talk more about the health policy implications of the 2016 election.

One thing is certain: The outcome of this year’s election will usher in profound change for the American healthcare system. It also means a great deal of uncertainty for physicians, hospital systems, insurers, patients, and healthcare providers more broadly for weeks, months, or even years to come.

The Policy Proposals

Democratic presidential nominee Hillary Clinton has vowed to keep, strengthen, and “fix” the ACA, with proposals that include allowing people to begin buying into Medicare at age 55 and eliminating the Cadillac tax, plus a vow to defend access to reproductive healthcare. Republican nominee Donald Trump has the seven-point “Healthcare Reform to Make America Great Again,” which has as its first pillar to “completely replace Obamacare.”

While Clinton’s platform is highly detailed, Trump has offered few specifics with regard to its replacement, “just a set of general principles,” says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. “His supporters are just not focused on what the healthcare bill of the future would look like,” he adds.

Under majority Republican leadership, “it’s absolutely clear,” Blendon says, that the party would attempt to repeal the ACA. That would mean millions of people could lose insurance coverage or face higher levels of cost-sharing, benefits would be less comprehensive, and government regulation would decrease, leading to fewer directives for physicians and providers, he says.

A Democratic sweep of the executive and legislative branches would likely bring more funding for the National Institutes of Health and the Centers for Disease Control and Prevention. It might also lead to the introduction of a government alternative insurance plan that would compete with private insurance for those under age 65, Blendon explains.

“There’d be more money spent, but there’d be much more government regulation, including discussions of Medicare price limits on certain types of drugs,” he says.

Healthcare, though, has been caught in the middle of a host of broader issues, Blendon says.

“Put very simply, you almost have three parties that are running,” he says. “You have Democratic, which is [the] more liberal-moderate party, which is basically running on a health platform that is continuing Obama’s eight years but enlarging it in a number of areas. You have the party of the Republicans strictly in the Congress, which are running as a conservative party, which is to get rid of part of the ACA, to slow Medicare costs, and very concerned with a tax cut broadly and restraining federal optional expenditures in the future.

“The third is Mr. Trump, but it’s not widely understood unless you follow European political situations a lot,” Blendon says. “Mr. Trump is actually running what would be called in Europe a nationalist party. Their issues are a bit different.”

Key components of Trump’s seven-point healthcare plan embrace some historical or current Republican policy ideas. These include using tax-free health savings accounts, allowing tax deductions for insurance premiums, and providing Medicaid block grants to states (though he has vowed not to cut overall Medicaid spending).

But Trump also breaks with the party, promising not to alter Medicare, proposing, like Clinton, to allow Medicare to negotiate pharmaceutical drug prices, and considering the idea of allowing pharmaceuticals to be imported from overseas, also like his Democratic opponent.

“I believe on the healthcare issue, he will be somewhat deferential to what the Republican leaders want their healthcare bill to look like in the future … not necessarily because that’s his particular choice but because he has a whole other agenda, which he says over and over is really important to him, and he needs the Republican leadership [to support it],” Blendon says.

How Will Things Get Done?

According to a Brookings Institution policy document published earlier this year, anyone proposing healthcare policy changes will confront “a daunting negotiation with powerful stakeholders to defend and enhance their varied interests” following the 2016 election.1

Three possible scenarios include a full Democratic president and Congress, a full Republican president and Congress, or a split presidency and Congress (including the two houses going each to the other party).

“If there is a split in the House and Senate, will things get done?” says Bradley Flansbaum, DO, MPH, MHM, a member of SHM’s Public Policy Committee. “Democrats don’t want to indicate the law has flaws and needs fixes. That admission invites the GOP to say, ‘See, it’s broken.’ Conversely, if Republicans do try to work with anyone on the other side of the aisle, they will be branded a pariah.”

One hospitalist sees Congress as the main force behind whether the ACA is kept intact.

“Congress holds the purse strings and has the control to chip away at the financial underpinnings until those toothpicks that hold up the Obamacare elephant break and it comes crashing down,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee.

ACA Fixes?

One option Clinton has proposed is a federally administered public alternative to private insurers in the ACA marketplace, particularly as more companies leave exchanges across the country. Blendon says there is some concern over the idea’s viability since, while it could help keep pricing competitive, it might just “attract some of the sickest people because they’ll feel it provides more financial security.”

“A very high priority for a Clinton administration and a Democratic Congress [is] to get in there with a rescue team, and this is an issue of providing wraparound protection for [insurance] companies that basically end up with either older or sicker people than they had at all anticipated and some sort of a financial cushion to carry them into other years,” Blendon says.

In its policy paper, the Brookings Institution says any serious Republican idea to repeal the ACA should offer an alternative to replace the healthcare bill’s spending reductions, particularly since the Congressional Budget Office estimates repeal of the ACA would increase direct Medicare spending by $802 billion over the next decade, possibly accelerating the depletion of the program’s trust fund.1

“I think what would happen would be some amount of what the Republican leadership has talked about, some sort of a partial alternative to the ACA, and it would cover less people and less benefits, but there would be an absolute plan that they would try to have in place,” Blendon says.

But only time will tell how the election will affect hospitalists in their day-to-day work.

“Unfortunately, we’re still not at a stage that you could say to somebody, ‘This is what the next five years are going to look like; that’s how you should think about what your hospital and practice should be thinking,’” Blendon says. “You’re much more stuck with, ‘There is uncertainty here.’” TH

Kelly April Tyrrell is a freelance writer in Madison, Wis.

Reference

1. Rivlin AM, Reischauer RD. Health policy issues and the 2016 presidential election. Brookings Institution website. Accessed August 31, 2016.

For Health Policy, State Races Matter, Too, in 2016

As Democrat Hillary Clinton and Republican Donald Trump vie for the U.S. presidency, a host of state-level political races affecting health policy will also play out across the country.

Most significant in individual states is whether to expand Medicaid. As of September 2016, 19 states had still not expanded the federal entitlement to people with incomes 138 percent above the federal poverty level.

“On a statewide level, the obvious issue of main concern to hospitalists will be Medicaid expansion,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee. “I think as state-level elections unfold, the makeup of state legislatures will impact whether expansion happens or not.”

If Clinton is elected, states with Democratic governors are likely to expand Medicaid if they have not already done so, says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. He suspects conservative Republican governors might hold out longer.

“In the states that haven’t expanded Medicaid, the election of the governor and the legislature matters a great deal because if Clinton wins that means that we’re not going to repeal the [ACA], you’re not holding the line for the new Republican plan, it’s not going to be repealed in the next four years, and the question is, does your state deny the funds for the coverage and income it gets over a matter of principle?” says Blendon.

Dr. Lenchus says issues like scope-of-practice changes could impact policies for physicians in individual states as well, such that, in some states, discharge summaries following a hospital visit could be sent to nurse practitioners or physicians assistants instead of family physicians.

Bigger changes could also be on the horizon as a little-mentioned provision of the ACA, called Section 1332, becomes a possibility in 2017 if the law survives. It allows individual states to apply for waivers to eschew all or parts of the ACA in favor of plausible attempts to create customized state-level health reform.

In Colorado, this appears as a referendum in the upcoming election for universal healthcare, called ColoradoCare. In Hawaii, it is an expansion of its four-decade-old Hawaii Prepaid Health Care Act, based on employer-provided insurance combined with subsidies and limits on premium costs. Waivers must be approved by the U.S. Department of Health & Human Services and the U.S. Department of the Treasury.

Blendon believes a public option to private health insurance is most likely at the state level rather than at the federal government level under a Section 1332 waiver.

“I would expect that some number of states, particularly without enough plans coverage [as some companies leave the ACA marketplace], would argue that the states should offer a plan, which would be run by the state government and subsidized,” says Blendon.

–Kelly April Terrell

Editor's Note: Listen to Robert Blendon talk more about the health policy implications of the 2016 election.

One thing is certain: The outcome of this year’s election will usher in profound change for the American healthcare system. It also means a great deal of uncertainty for physicians, hospital systems, insurers, patients, and healthcare providers more broadly for weeks, months, or even years to come.

The Policy Proposals

Democratic presidential nominee Hillary Clinton has vowed to keep, strengthen, and “fix” the ACA, with proposals that include allowing people to begin buying into Medicare at age 55 and eliminating the Cadillac tax, plus a vow to defend access to reproductive healthcare. Republican nominee Donald Trump has the seven-point “Healthcare Reform to Make America Great Again,” which has as its first pillar to “completely replace Obamacare.”

While Clinton’s platform is highly detailed, Trump has offered few specifics with regard to its replacement, “just a set of general principles,” says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. “His supporters are just not focused on what the healthcare bill of the future would look like,” he adds.

Under majority Republican leadership, “it’s absolutely clear,” Blendon says, that the party would attempt to repeal the ACA. That would mean millions of people could lose insurance coverage or face higher levels of cost-sharing, benefits would be less comprehensive, and government regulation would decrease, leading to fewer directives for physicians and providers, he says.

A Democratic sweep of the executive and legislative branches would likely bring more funding for the National Institutes of Health and the Centers for Disease Control and Prevention. It might also lead to the introduction of a government alternative insurance plan that would compete with private insurance for those under age 65, Blendon explains.

“There’d be more money spent, but there’d be much more government regulation, including discussions of Medicare price limits on certain types of drugs,” he says.

Healthcare, though, has been caught in the middle of a host of broader issues, Blendon says.

“Put very simply, you almost have three parties that are running,” he says. “You have Democratic, which is [the] more liberal-moderate party, which is basically running on a health platform that is continuing Obama’s eight years but enlarging it in a number of areas. You have the party of the Republicans strictly in the Congress, which are running as a conservative party, which is to get rid of part of the ACA, to slow Medicare costs, and very concerned with a tax cut broadly and restraining federal optional expenditures in the future.

“The third is Mr. Trump, but it’s not widely understood unless you follow European political situations a lot,” Blendon says. “Mr. Trump is actually running what would be called in Europe a nationalist party. Their issues are a bit different.”

Key components of Trump’s seven-point healthcare plan embrace some historical or current Republican policy ideas. These include using tax-free health savings accounts, allowing tax deductions for insurance premiums, and providing Medicaid block grants to states (though he has vowed not to cut overall Medicaid spending).

But Trump also breaks with the party, promising not to alter Medicare, proposing, like Clinton, to allow Medicare to negotiate pharmaceutical drug prices, and considering the idea of allowing pharmaceuticals to be imported from overseas, also like his Democratic opponent.

“I believe on the healthcare issue, he will be somewhat deferential to what the Republican leaders want their healthcare bill to look like in the future … not necessarily because that’s his particular choice but because he has a whole other agenda, which he says over and over is really important to him, and he needs the Republican leadership [to support it],” Blendon says.

How Will Things Get Done?

According to a Brookings Institution policy document published earlier this year, anyone proposing healthcare policy changes will confront “a daunting negotiation with powerful stakeholders to defend and enhance their varied interests” following the 2016 election.1

Three possible scenarios include a full Democratic president and Congress, a full Republican president and Congress, or a split presidency and Congress (including the two houses going each to the other party).

“If there is a split in the House and Senate, will things get done?” says Bradley Flansbaum, DO, MPH, MHM, a member of SHM’s Public Policy Committee. “Democrats don’t want to indicate the law has flaws and needs fixes. That admission invites the GOP to say, ‘See, it’s broken.’ Conversely, if Republicans do try to work with anyone on the other side of the aisle, they will be branded a pariah.”

One hospitalist sees Congress as the main force behind whether the ACA is kept intact.

“Congress holds the purse strings and has the control to chip away at the financial underpinnings until those toothpicks that hold up the Obamacare elephant break and it comes crashing down,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee.

ACA Fixes?

One option Clinton has proposed is a federally administered public alternative to private insurers in the ACA marketplace, particularly as more companies leave exchanges across the country. Blendon says there is some concern over the idea’s viability since, while it could help keep pricing competitive, it might just “attract some of the sickest people because they’ll feel it provides more financial security.”

“A very high priority for a Clinton administration and a Democratic Congress [is] to get in there with a rescue team, and this is an issue of providing wraparound protection for [insurance] companies that basically end up with either older or sicker people than they had at all anticipated and some sort of a financial cushion to carry them into other years,” Blendon says.

In its policy paper, the Brookings Institution says any serious Republican idea to repeal the ACA should offer an alternative to replace the healthcare bill’s spending reductions, particularly since the Congressional Budget Office estimates repeal of the ACA would increase direct Medicare spending by $802 billion over the next decade, possibly accelerating the depletion of the program’s trust fund.1

“I think what would happen would be some amount of what the Republican leadership has talked about, some sort of a partial alternative to the ACA, and it would cover less people and less benefits, but there would be an absolute plan that they would try to have in place,” Blendon says.

But only time will tell how the election will affect hospitalists in their day-to-day work.

“Unfortunately, we’re still not at a stage that you could say to somebody, ‘This is what the next five years are going to look like; that’s how you should think about what your hospital and practice should be thinking,’” Blendon says. “You’re much more stuck with, ‘There is uncertainty here.’” TH

Kelly April Tyrrell is a freelance writer in Madison, Wis.

Reference

1. Rivlin AM, Reischauer RD. Health policy issues and the 2016 presidential election. Brookings Institution website. Accessed August 31, 2016.

For Health Policy, State Races Matter, Too, in 2016

As Democrat Hillary Clinton and Republican Donald Trump vie for the U.S. presidency, a host of state-level political races affecting health policy will also play out across the country.

Most significant in individual states is whether to expand Medicaid. As of September 2016, 19 states had still not expanded the federal entitlement to people with incomes 138 percent above the federal poverty level.

“On a statewide level, the obvious issue of main concern to hospitalists will be Medicaid expansion,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee. “I think as state-level elections unfold, the makeup of state legislatures will impact whether expansion happens or not.”

If Clinton is elected, states with Democratic governors are likely to expand Medicaid if they have not already done so, says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. He suspects conservative Republican governors might hold out longer.

“In the states that haven’t expanded Medicaid, the election of the governor and the legislature matters a great deal because if Clinton wins that means that we’re not going to repeal the [ACA], you’re not holding the line for the new Republican plan, it’s not going to be repealed in the next four years, and the question is, does your state deny the funds for the coverage and income it gets over a matter of principle?” says Blendon.

Dr. Lenchus says issues like scope-of-practice changes could impact policies for physicians in individual states as well, such that, in some states, discharge summaries following a hospital visit could be sent to nurse practitioners or physicians assistants instead of family physicians.

Bigger changes could also be on the horizon as a little-mentioned provision of the ACA, called Section 1332, becomes a possibility in 2017 if the law survives. It allows individual states to apply for waivers to eschew all or parts of the ACA in favor of plausible attempts to create customized state-level health reform.

In Colorado, this appears as a referendum in the upcoming election for universal healthcare, called ColoradoCare. In Hawaii, it is an expansion of its four-decade-old Hawaii Prepaid Health Care Act, based on employer-provided insurance combined with subsidies and limits on premium costs. Waivers must be approved by the U.S. Department of Health & Human Services and the U.S. Department of the Treasury.

Blendon believes a public option to private health insurance is most likely at the state level rather than at the federal government level under a Section 1332 waiver.

“I would expect that some number of states, particularly without enough plans coverage [as some companies leave the ACA marketplace], would argue that the states should offer a plan, which would be run by the state government and subsidized,” says Blendon.

–Kelly April Terrell

Editor's Note: Listen to Robert Blendon talk more about the health policy implications of the 2016 election.

One thing is certain: The outcome of this year’s election will usher in profound change for the American healthcare system. It also means a great deal of uncertainty for physicians, hospital systems, insurers, patients, and healthcare providers more broadly for weeks, months, or even years to come.

The Policy Proposals

Democratic presidential nominee Hillary Clinton has vowed to keep, strengthen, and “fix” the ACA, with proposals that include allowing people to begin buying into Medicare at age 55 and eliminating the Cadillac tax, plus a vow to defend access to reproductive healthcare. Republican nominee Donald Trump has the seven-point “Healthcare Reform to Make America Great Again,” which has as its first pillar to “completely replace Obamacare.”

While Clinton’s platform is highly detailed, Trump has offered few specifics with regard to its replacement, “just a set of general principles,” says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. “His supporters are just not focused on what the healthcare bill of the future would look like,” he adds.

Under majority Republican leadership, “it’s absolutely clear,” Blendon says, that the party would attempt to repeal the ACA. That would mean millions of people could lose insurance coverage or face higher levels of cost-sharing, benefits would be less comprehensive, and government regulation would decrease, leading to fewer directives for physicians and providers, he says.

A Democratic sweep of the executive and legislative branches would likely bring more funding for the National Institutes of Health and the Centers for Disease Control and Prevention. It might also lead to the introduction of a government alternative insurance plan that would compete with private insurance for those under age 65, Blendon explains.

“There’d be more money spent, but there’d be much more government regulation, including discussions of Medicare price limits on certain types of drugs,” he says.

Healthcare, though, has been caught in the middle of a host of broader issues, Blendon says.

“Put very simply, you almost have three parties that are running,” he says. “You have Democratic, which is [the] more liberal-moderate party, which is basically running on a health platform that is continuing Obama’s eight years but enlarging it in a number of areas. You have the party of the Republicans strictly in the Congress, which are running as a conservative party, which is to get rid of part of the ACA, to slow Medicare costs, and very concerned with a tax cut broadly and restraining federal optional expenditures in the future.

“The third is Mr. Trump, but it’s not widely understood unless you follow European political situations a lot,” Blendon says. “Mr. Trump is actually running what would be called in Europe a nationalist party. Their issues are a bit different.”

Key components of Trump’s seven-point healthcare plan embrace some historical or current Republican policy ideas. These include using tax-free health savings accounts, allowing tax deductions for insurance premiums, and providing Medicaid block grants to states (though he has vowed not to cut overall Medicaid spending).

But Trump also breaks with the party, promising not to alter Medicare, proposing, like Clinton, to allow Medicare to negotiate pharmaceutical drug prices, and considering the idea of allowing pharmaceuticals to be imported from overseas, also like his Democratic opponent.

“I believe on the healthcare issue, he will be somewhat deferential to what the Republican leaders want their healthcare bill to look like in the future … not necessarily because that’s his particular choice but because he has a whole other agenda, which he says over and over is really important to him, and he needs the Republican leadership [to support it],” Blendon says.

How Will Things Get Done?

According to a Brookings Institution policy document published earlier this year, anyone proposing healthcare policy changes will confront “a daunting negotiation with powerful stakeholders to defend and enhance their varied interests” following the 2016 election.1

Three possible scenarios include a full Democratic president and Congress, a full Republican president and Congress, or a split presidency and Congress (including the two houses going each to the other party).

“If there is a split in the House and Senate, will things get done?” says Bradley Flansbaum, DO, MPH, MHM, a member of SHM’s Public Policy Committee. “Democrats don’t want to indicate the law has flaws and needs fixes. That admission invites the GOP to say, ‘See, it’s broken.’ Conversely, if Republicans do try to work with anyone on the other side of the aisle, they will be branded a pariah.”

One hospitalist sees Congress as the main force behind whether the ACA is kept intact.

“Congress holds the purse strings and has the control to chip away at the financial underpinnings until those toothpicks that hold up the Obamacare elephant break and it comes crashing down,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee.

ACA Fixes?

One option Clinton has proposed is a federally administered public alternative to private insurers in the ACA marketplace, particularly as more companies leave exchanges across the country. Blendon says there is some concern over the idea’s viability since, while it could help keep pricing competitive, it might just “attract some of the sickest people because they’ll feel it provides more financial security.”

“A very high priority for a Clinton administration and a Democratic Congress [is] to get in there with a rescue team, and this is an issue of providing wraparound protection for [insurance] companies that basically end up with either older or sicker people than they had at all anticipated and some sort of a financial cushion to carry them into other years,” Blendon says.

In its policy paper, the Brookings Institution says any serious Republican idea to repeal the ACA should offer an alternative to replace the healthcare bill’s spending reductions, particularly since the Congressional Budget Office estimates repeal of the ACA would increase direct Medicare spending by $802 billion over the next decade, possibly accelerating the depletion of the program’s trust fund.1

“I think what would happen would be some amount of what the Republican leadership has talked about, some sort of a partial alternative to the ACA, and it would cover less people and less benefits, but there would be an absolute plan that they would try to have in place,” Blendon says.

But only time will tell how the election will affect hospitalists in their day-to-day work.

“Unfortunately, we’re still not at a stage that you could say to somebody, ‘This is what the next five years are going to look like; that’s how you should think about what your hospital and practice should be thinking,’” Blendon says. “You’re much more stuck with, ‘There is uncertainty here.’” TH

Kelly April Tyrrell is a freelance writer in Madison, Wis.

Reference

1. Rivlin AM, Reischauer RD. Health policy issues and the 2016 presidential election. Brookings Institution website. Accessed August 31, 2016.

For Health Policy, State Races Matter, Too, in 2016

As Democrat Hillary Clinton and Republican Donald Trump vie for the U.S. presidency, a host of state-level political races affecting health policy will also play out across the country.

Most significant in individual states is whether to expand Medicaid. As of September 2016, 19 states had still not expanded the federal entitlement to people with incomes 138 percent above the federal poverty level.

“On a statewide level, the obvious issue of main concern to hospitalists will be Medicaid expansion,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee. “I think as state-level elections unfold, the makeup of state legislatures will impact whether expansion happens or not.”

If Clinton is elected, states with Democratic governors are likely to expand Medicaid if they have not already done so, says Robert Blendon, the Richard L. Menschel Professor of Public Health at Harvard T.H. Chan School of Public Health (HSPH) and a professor of health policy and political analysis at HSPH and the Harvard Kennedy School of Government. He suspects conservative Republican governors might hold out longer.

“In the states that haven’t expanded Medicaid, the election of the governor and the legislature matters a great deal because if Clinton wins that means that we’re not going to repeal the [ACA], you’re not holding the line for the new Republican plan, it’s not going to be repealed in the next four years, and the question is, does your state deny the funds for the coverage and income it gets over a matter of principle?” says Blendon.

Dr. Lenchus says issues like scope-of-practice changes could impact policies for physicians in individual states as well, such that, in some states, discharge summaries following a hospital visit could be sent to nurse practitioners or physicians assistants instead of family physicians.

Bigger changes could also be on the horizon as a little-mentioned provision of the ACA, called Section 1332, becomes a possibility in 2017 if the law survives. It allows individual states to apply for waivers to eschew all or parts of the ACA in favor of plausible attempts to create customized state-level health reform.

In Colorado, this appears as a referendum in the upcoming election for universal healthcare, called ColoradoCare. In Hawaii, it is an expansion of its four-decade-old Hawaii Prepaid Health Care Act, based on employer-provided insurance combined with subsidies and limits on premium costs. Waivers must be approved by the U.S. Department of Health & Human Services and the U.S. Department of the Treasury.

Blendon believes a public option to private health insurance is most likely at the state level rather than at the federal government level under a Section 1332 waiver.

“I would expect that some number of states, particularly without enough plans coverage [as some companies leave the ACA marketplace], would argue that the states should offer a plan, which would be run by the state government and subsidized,” says Blendon.

–Kelly April Terrell

Clinical Question: Can an objective measurement of critical illness inform intensive care unit (ICU) transfer timeliness?

Background: Early intervention has shown mortality benefit in many critical illness syndromes, yet heterogeneity in timing of ICU transfer exists. Previous studies examining ICU transfer timeliness have mostly focused on subjective criteria.

Study Design: Retrospective observational cohort study.

Setting: Medical-surgical units at five hospitals including the University of Chicago and NorthShore University HealthSystem in Illinois.

Synopsis: All medical-surgical ward patients between November 2008 and January 2013 were scored using eCART, a previously validated objective scoring system, to decide when transfer was appropriate. Of those, 3,789 patients reached the predetermined threshold for critical illness. Transfers more than six hours after crossing the threshold were considered delayed. Patients with delayed transfer had a statistically significant increase in length of stay (LOS) and in-hospital mortality (33.2% versus 24.5%; P < 0.001), and the mortality increase was linear, with a 3% increase in odds for each one hour of further transfer delay (P < 0.001). The rate of change of eCART score did influence time of transfer, and the authors suggest that rapid changes were more likely to be recognized. They postulate that routine implementation of eCART or similar objective scoring may lead to earlier recognition of necessary ICU transfer and thus improve mortality and LOS, and they suggest this as a topic for future trials.

Bottom Line: Delayed ICU transfer negatively affects LOS and in-hospital mortality. Objective criteria may identify more appropriate timing of transfer. Clinical trials to investigate this are warranted.

Citation: Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation [published online ahead of print June 28, 2016]. J Hosp Med. doi:10.1002/jhm.2630.

Short Take

Intranasal Live Attenuated Influenza Vaccine Not Recommended

The Centers for Disease Control and Prevention recommends against use of the nasal spray live attenuated influenza vaccine. This is based on data showing poor effectiveness in prior years.

Citation: ACIP votes down use of LAIV for 2016-2017 flu season [press release]. CDC website.

Clinical Question: Can an objective measurement of critical illness inform intensive care unit (ICU) transfer timeliness?

Background: Early intervention has shown mortality benefit in many critical illness syndromes, yet heterogeneity in timing of ICU transfer exists. Previous studies examining ICU transfer timeliness have mostly focused on subjective criteria.

Study Design: Retrospective observational cohort study.

Setting: Medical-surgical units at five hospitals including the University of Chicago and NorthShore University HealthSystem in Illinois.

Synopsis: All medical-surgical ward patients between November 2008 and January 2013 were scored using eCART, a previously validated objective scoring system, to decide when transfer was appropriate. Of those, 3,789 patients reached the predetermined threshold for critical illness. Transfers more than six hours after crossing the threshold were considered delayed. Patients with delayed transfer had a statistically significant increase in length of stay (LOS) and in-hospital mortality (33.2% versus 24.5%; P < 0.001), and the mortality increase was linear, with a 3% increase in odds for each one hour of further transfer delay (P < 0.001). The rate of change of eCART score did influence time of transfer, and the authors suggest that rapid changes were more likely to be recognized. They postulate that routine implementation of eCART or similar objective scoring may lead to earlier recognition of necessary ICU transfer and thus improve mortality and LOS, and they suggest this as a topic for future trials.

Bottom Line: Delayed ICU transfer negatively affects LOS and in-hospital mortality. Objective criteria may identify more appropriate timing of transfer. Clinical trials to investigate this are warranted.

Citation: Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation [published online ahead of print June 28, 2016]. J Hosp Med. doi:10.1002/jhm.2630.

Short Take

Intranasal Live Attenuated Influenza Vaccine Not Recommended

The Centers for Disease Control and Prevention recommends against use of the nasal spray live attenuated influenza vaccine. This is based on data showing poor effectiveness in prior years.

Citation: ACIP votes down use of LAIV for 2016-2017 flu season [press release]. CDC website.

Clinical Question: Can an objective measurement of critical illness inform intensive care unit (ICU) transfer timeliness?

Background: Early intervention has shown mortality benefit in many critical illness syndromes, yet heterogeneity in timing of ICU transfer exists. Previous studies examining ICU transfer timeliness have mostly focused on subjective criteria.

Study Design: Retrospective observational cohort study.

Setting: Medical-surgical units at five hospitals including the University of Chicago and NorthShore University HealthSystem in Illinois.

Synopsis: All medical-surgical ward patients between November 2008 and January 2013 were scored using eCART, a previously validated objective scoring system, to decide when transfer was appropriate. Of those, 3,789 patients reached the predetermined threshold for critical illness. Transfers more than six hours after crossing the threshold were considered delayed. Patients with delayed transfer had a statistically significant increase in length of stay (LOS) and in-hospital mortality (33.2% versus 24.5%; P < 0.001), and the mortality increase was linear, with a 3% increase in odds for each one hour of further transfer delay (P < 0.001). The rate of change of eCART score did influence time of transfer, and the authors suggest that rapid changes were more likely to be recognized. They postulate that routine implementation of eCART or similar objective scoring may lead to earlier recognition of necessary ICU transfer and thus improve mortality and LOS, and they suggest this as a topic for future trials.

Bottom Line: Delayed ICU transfer negatively affects LOS and in-hospital mortality. Objective criteria may identify more appropriate timing of transfer. Clinical trials to investigate this are warranted.

Citation: Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation [published online ahead of print June 28, 2016]. J Hosp Med. doi:10.1002/jhm.2630.

Short Take

Intranasal Live Attenuated Influenza Vaccine Not Recommended

The Centers for Disease Control and Prevention recommends against use of the nasal spray live attenuated influenza vaccine. This is based on data showing poor effectiveness in prior years.

Citation: ACIP votes down use of LAIV for 2016-2017 flu season [press release]. CDC website.

Clinical Question: Does increased fluid administration in patients with sepsis with intermediate lactate levels improve outcomes?

Background: The Surviving Sepsis Campaign bundle, which improves ED mortality, targets patients with hypotension or lactate levels >4 mmol/L. No similar optimal treatment strategy exists for less severe sepsis patients even though such patients are more common in hospitalized populations.

Study Design: Retrospective study of a quality improvement bundle.

Setting: 21 community-based hospitals in the Kaiser Permanente Northern California system.

Synopsis: This study evaluated implementation of a treatment bundle for 18,122 hemodynamically stable sepsis patients presenting to the ED with lactate levels between 2 and 4 mmol/L during the 12 months prior to and after bundle implementation. The bundle included antibiotic administration within three hours, repeated lactate levels within four hours, and 30 mL/kg or ≥2 L of intravenous fluids within three hours of initial lactate result. Patients with kidney disease and/or heart failure were separately evaluated because of the perceived risk of fluid administration.

Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI, 0.66–0.99; P = 0.04). Significant reductions in hospital mortality were observed in patients with heart failure and/or kidney disease (P < 0.01) but not without (P > 0.4). This correlated with increased fluid administration in patients with heart failure and/or kidney disease following bundle implementation. This is not a randomized controlled study, which invites biases and confounding.

Bottom Line: Increased fluid administration improved mortality in patients with kidney disease and heart failure presenting with sepsis.

Reference: Liu V, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264-1270.

Short Take

New Framework for Learners’ Clinical Reasoning

A qualitative study involving 37 emergency medicine residents found that clinical reasoning through individual cases progresses from case framing (phase 1) to pattern recognition (phase 2), then self-monitoring (phase 3).

Citation: Adams E, Goyder C, Heneghan C, Brand L, Ajjawi R. Clinical reasoning of junior doctors in emergency medicine: a grounded theory study [published online ahead of print June 23, 2016]. Emerg Med J. doi:10.1136/emermed-2015-205650.

Clinical Question: Does increased fluid administration in patients with sepsis with intermediate lactate levels improve outcomes?

Background: The Surviving Sepsis Campaign bundle, which improves ED mortality, targets patients with hypotension or lactate levels >4 mmol/L. No similar optimal treatment strategy exists for less severe sepsis patients even though such patients are more common in hospitalized populations.

Study Design: Retrospective study of a quality improvement bundle.

Setting: 21 community-based hospitals in the Kaiser Permanente Northern California system.

Synopsis: This study evaluated implementation of a treatment bundle for 18,122 hemodynamically stable sepsis patients presenting to the ED with lactate levels between 2 and 4 mmol/L during the 12 months prior to and after bundle implementation. The bundle included antibiotic administration within three hours, repeated lactate levels within four hours, and 30 mL/kg or ≥2 L of intravenous fluids within three hours of initial lactate result. Patients with kidney disease and/or heart failure were separately evaluated because of the perceived risk of fluid administration.

Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI, 0.66–0.99; P = 0.04). Significant reductions in hospital mortality were observed in patients with heart failure and/or kidney disease (P < 0.01) but not without (P > 0.4). This correlated with increased fluid administration in patients with heart failure and/or kidney disease following bundle implementation. This is not a randomized controlled study, which invites biases and confounding.

Bottom Line: Increased fluid administration improved mortality in patients with kidney disease and heart failure presenting with sepsis.

Reference: Liu V, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264-1270.

Short Take

New Framework for Learners’ Clinical Reasoning

A qualitative study involving 37 emergency medicine residents found that clinical reasoning through individual cases progresses from case framing (phase 1) to pattern recognition (phase 2), then self-monitoring (phase 3).

Citation: Adams E, Goyder C, Heneghan C, Brand L, Ajjawi R. Clinical reasoning of junior doctors in emergency medicine: a grounded theory study [published online ahead of print June 23, 2016]. Emerg Med J. doi:10.1136/emermed-2015-205650.

Clinical Question: Does increased fluid administration in patients with sepsis with intermediate lactate levels improve outcomes?

Background: The Surviving Sepsis Campaign bundle, which improves ED mortality, targets patients with hypotension or lactate levels >4 mmol/L. No similar optimal treatment strategy exists for less severe sepsis patients even though such patients are more common in hospitalized populations.

Study Design: Retrospective study of a quality improvement bundle.

Setting: 21 community-based hospitals in the Kaiser Permanente Northern California system.

Synopsis: This study evaluated implementation of a treatment bundle for 18,122 hemodynamically stable sepsis patients presenting to the ED with lactate levels between 2 and 4 mmol/L during the 12 months prior to and after bundle implementation. The bundle included antibiotic administration within three hours, repeated lactate levels within four hours, and 30 mL/kg or ≥2 L of intravenous fluids within three hours of initial lactate result. Patients with kidney disease and/or heart failure were separately evaluated because of the perceived risk of fluid administration.

Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI, 0.66–0.99; P = 0.04). Significant reductions in hospital mortality were observed in patients with heart failure and/or kidney disease (P < 0.01) but not without (P > 0.4). This correlated with increased fluid administration in patients with heart failure and/or kidney disease following bundle implementation. This is not a randomized controlled study, which invites biases and confounding.

Bottom Line: Increased fluid administration improved mortality in patients with kidney disease and heart failure presenting with sepsis.

Reference: Liu V, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264-1270.

Short Take

New Framework for Learners’ Clinical Reasoning

A qualitative study involving 37 emergency medicine residents found that clinical reasoning through individual cases progresses from case framing (phase 1) to pattern recognition (phase 2), then self-monitoring (phase 3).

Citation: Adams E, Goyder C, Heneghan C, Brand L, Ajjawi R. Clinical reasoning of junior doctors in emergency medicine: a grounded theory study [published online ahead of print June 23, 2016]. Emerg Med J. doi:10.1136/emermed-2015-205650.

October 16–22 is the National Association for Healthcare Quality’s “Healthcare Quality Week,” and SHM’s Center for Hospital Innovation & Improvement provides a variety of resources, tools, and programs to help address quality and patient safety issues at your institution. Find out how SHM can help you improve patient safety and outcomes through our Center for Hospital Innovation & Improvement at www.hospialmedicine.org/QI.

October 16–22 is the National Association for Healthcare Quality’s “Healthcare Quality Week,” and SHM’s Center for Hospital Innovation & Improvement provides a variety of resources, tools, and programs to help address quality and patient safety issues at your institution. Find out how SHM can help you improve patient safety and outcomes through our Center for Hospital Innovation & Improvement at www.hospialmedicine.org/QI.

October 16–22 is the National Association for Healthcare Quality’s “Healthcare Quality Week,” and SHM’s Center for Hospital Innovation & Improvement provides a variety of resources, tools, and programs to help address quality and patient safety issues at your institution. Find out how SHM can help you improve patient safety and outcomes through our Center for Hospital Innovation & Improvement at www.hospialmedicine.org/QI.

• Model 1: Mentors/Mentees. Less experienced administrators will be paired with seasoned professionals to gain more experience or exposure.
• Model 2: Buddy System. Administrators at any level of expertise or experience will be paired with a peer so they both can learn from each other.

Interested in being a mentor or mentee for the 2017 program? Complete the online form at www.hospitalmedicine.org/pamentor used to match you up to other individuals who have similar needs for improvement.

• Model 1: Mentors/Mentees. Less experienced administrators will be paired with seasoned professionals to gain more experience or exposure.
• Model 2: Buddy System. Administrators at any level of expertise or experience will be paired with a peer so they both can learn from each other.

Interested in being a mentor or mentee for the 2017 program? Complete the online form at www.hospitalmedicine.org/pamentor used to match you up to other individuals who have similar needs for improvement.

• Model 1: Mentors/Mentees. Less experienced administrators will be paired with seasoned professionals to gain more experience or exposure.
• Model 2: Buddy System. Administrators at any level of expertise or experience will be paired with a peer so they both can learn from each other.

Interested in being a mentor or mentee for the 2017 program? Complete the online form at www.hospitalmedicine.org/pamentor used to match you up to other individuals who have similar needs for improvement.

The application is open through November 30, with a decision on or before December 31, 2016. Apply now and learn how you can join other hospitalists who have earned this exclusive designation and recognition at www.hospitalmedicine.org/fellows.

The application is open through November 30, with a decision on or before December 31, 2016. Apply now and learn how you can join other hospitalists who have earned this exclusive designation and recognition at www.hospitalmedicine.org/fellows.

The application is open through November 30, with a decision on or before December 31, 2016. Apply now and learn how you can join other hospitalists who have earned this exclusive designation and recognition at www.hospitalmedicine.org/fellows.

Kevin Conrad, MD, MBA, could always picture being a doctor, given that he enjoyed the sciences and wanted a job where he could work with people. He has more trouble figuring out how people don’t enjoy the detective work that comes with medicine.

“I have a hard time imagining what people do besides people in the sciences,” he says. “In sciences, you deal with facts, you deal with numbers, you deal with data, and you put it together and you come to conclusions. And to me, that seemed like a career pathway as opposed to, say, a field like law or writing or whatnot. I could never wrap my head around what they actually do in a given day.”

Dr. Conrad’s passion for the sciences hasn’t waned yet. He serves as the medical director of community affairs and healthy policy at Ochsner Health Systems of New Orleans, where he focuses on systems improvement. He published his first book this year, Absolute Hospital Medicine Review: An Intensive Question and Answer Guide, and is working on his second tome.

And this year, he was named one of the eight new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist.

Question: What led you to a more hands-on medical field as opposed to being a basic or translational scientist?

Answer: I had some early exposure to lab work in high school and college and saw what they did and saw how they were sort of confined to labs for long periods of time and said, “No, I think that I would rather be kind of out there, combining science as well as interacting with people in the field.”

Q: When you started residency, was it clear to you that hospital medicine was where you wanted to go, or were you looking at a few different options?

A: Hospital medicine combined my interests in internal medicine, which is sort of a broad overview of all aspects of medicine and healthcare as well as being a little bit more intensive, a little bit more action-oriented. The patients tend to be a little bit more ill, require a little bit more acute attention, and that appealed to me as opposed to my training in internal medicine.

Q: What about the intensity of hospital medicine appeals to you?

A: As opposed to sitting down with a patient in an office setting, I think, in hospital medicine, I like the idea that you’re called from one semi-emergency to another and that you have to think quickly on your feet and move on to the new task. And the new tasks come in rapid sequence: You have one problem that you fix and then you’re called to do another one, and each and every day, it will tend to be sort of a different set of problems.

Q: What was the motivation to write the book and now working on the second?

A: I wanted to share my experience, and I felt I was in a position where I could not only share my personal practice experience as well as sort of collate the other material that has been written and published in hospital medicine. I also think there is a need right now to continue to define what hospital medicine is and show what we’re experts at as well as show our value to the system. We have an ambiguous practice, and people still aren’t quite sure what we do and what we’re expert at. So I think it’s our task to showcase this is what we do well, this is what we do better than other people, and this is our value to the system.

Q: So what is hospitalists’ value, and what are they experts in?

A: We’re experts at systems, hospital systems. … We understand better than anyone what goes on in the hospital, the physicians’ practice, the nursing practice, the administrative practice. … I mean, we’re there. We’re on the floors. No one has a better insight into the function of the hospital than the hospitalists. I think the other unique role we have is we see trends that other specialties don’t. We don’t really own our patients. Our patients come and go, but we tend to have a unique view of the practice of medicine that we see trends maybe before other specialists. … We see some of the failures of other systems.

Q: What is your least favorite part of being a hospitalist?

A: The clerical work. I think I probably speak for most people in that the clerical work is needed. It has become an increasing part of our practice in that now we spend a great deal of our time obviously in front of computers as opposed to at the bedside. The electronic medical record, which is good, which has served us well, becomes a greater and bigger part of our day, and so we find that it is too much a part of my day. I’m not saying it’s not needed because I think it has improved the quality of care we deliver, but it’s not something that you imagine that you should be doing as a physician. You are spending most of your day in front of a computer as opposed to most of the day with patients.

Q: What’s your favorite part of the job?

A: It has changed over my career. I think it probably started out in education. I enjoyed teaching medical students and residents, and certainly, that’s still a part of it, but then I think it has evolved into a little bit more of an academic interest. I just published my first book this past year and am working on my second book, and that has become sort of my bigger focus now. TH

Richard Quinn is a freelance writer in New Jersey.

Kevin Conrad, MD, MBA, could always picture being a doctor, given that he enjoyed the sciences and wanted a job where he could work with people. He has more trouble figuring out how people don’t enjoy the detective work that comes with medicine.

“I have a hard time imagining what people do besides people in the sciences,” he says. “In sciences, you deal with facts, you deal with numbers, you deal with data, and you put it together and you come to conclusions. And to me, that seemed like a career pathway as opposed to, say, a field like law or writing or whatnot. I could never wrap my head around what they actually do in a given day.”

Dr. Conrad’s passion for the sciences hasn’t waned yet. He serves as the medical director of community affairs and healthy policy at Ochsner Health Systems of New Orleans, where he focuses on systems improvement. He published his first book this year, Absolute Hospital Medicine Review: An Intensive Question and Answer Guide, and is working on his second tome.

And this year, he was named one of the eight new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist.

Question: What led you to a more hands-on medical field as opposed to being a basic or translational scientist?

Answer: I had some early exposure to lab work in high school and college and saw what they did and saw how they were sort of confined to labs for long periods of time and said, “No, I think that I would rather be kind of out there, combining science as well as interacting with people in the field.”

Q: When you started residency, was it clear to you that hospital medicine was where you wanted to go, or were you looking at a few different options?

A: Hospital medicine combined my interests in internal medicine, which is sort of a broad overview of all aspects of medicine and healthcare as well as being a little bit more intensive, a little bit more action-oriented. The patients tend to be a little bit more ill, require a little bit more acute attention, and that appealed to me as opposed to my training in internal medicine.

Q: What about the intensity of hospital medicine appeals to you?

A: As opposed to sitting down with a patient in an office setting, I think, in hospital medicine, I like the idea that you’re called from one semi-emergency to another and that you have to think quickly on your feet and move on to the new task. And the new tasks come in rapid sequence: You have one problem that you fix and then you’re called to do another one, and each and every day, it will tend to be sort of a different set of problems.

Q: What was the motivation to write the book and now working on the second?

A: I wanted to share my experience, and I felt I was in a position where I could not only share my personal practice experience as well as sort of collate the other material that has been written and published in hospital medicine. I also think there is a need right now to continue to define what hospital medicine is and show what we’re experts at as well as show our value to the system. We have an ambiguous practice, and people still aren’t quite sure what we do and what we’re expert at. So I think it’s our task to showcase this is what we do well, this is what we do better than other people, and this is our value to the system.

Q: So what is hospitalists’ value, and what are they experts in?

A: We’re experts at systems, hospital systems. … We understand better than anyone what goes on in the hospital, the physicians’ practice, the nursing practice, the administrative practice. … I mean, we’re there. We’re on the floors. No one has a better insight into the function of the hospital than the hospitalists. I think the other unique role we have is we see trends that other specialties don’t. We don’t really own our patients. Our patients come and go, but we tend to have a unique view of the practice of medicine that we see trends maybe before other specialists. … We see some of the failures of other systems.

Q: What is your least favorite part of being a hospitalist?

A: The clerical work. I think I probably speak for most people in that the clerical work is needed. It has become an increasing part of our practice in that now we spend a great deal of our time obviously in front of computers as opposed to at the bedside. The electronic medical record, which is good, which has served us well, becomes a greater and bigger part of our day, and so we find that it is too much a part of my day. I’m not saying it’s not needed because I think it has improved the quality of care we deliver, but it’s not something that you imagine that you should be doing as a physician. You are spending most of your day in front of a computer as opposed to most of the day with patients.

Q: What’s your favorite part of the job?

A: It has changed over my career. I think it probably started out in education. I enjoyed teaching medical students and residents, and certainly, that’s still a part of it, but then I think it has evolved into a little bit more of an academic interest. I just published my first book this past year and am working on my second book, and that has become sort of my bigger focus now. TH

Richard Quinn is a freelance writer in New Jersey.

Kevin Conrad, MD, MBA, could always picture being a doctor, given that he enjoyed the sciences and wanted a job where he could work with people. He has more trouble figuring out how people don’t enjoy the detective work that comes with medicine.

“I have a hard time imagining what people do besides people in the sciences,” he says. “In sciences, you deal with facts, you deal with numbers, you deal with data, and you put it together and you come to conclusions. And to me, that seemed like a career pathway as opposed to, say, a field like law or writing or whatnot. I could never wrap my head around what they actually do in a given day.”

Dr. Conrad’s passion for the sciences hasn’t waned yet. He serves as the medical director of community affairs and healthy policy at Ochsner Health Systems of New Orleans, where he focuses on systems improvement. He published his first book this year, Absolute Hospital Medicine Review: An Intensive Question and Answer Guide, and is working on his second tome.

And this year, he was named one of the eight new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist.

Question: What led you to a more hands-on medical field as opposed to being a basic or translational scientist?

Answer: I had some early exposure to lab work in high school and college and saw what they did and saw how they were sort of confined to labs for long periods of time and said, “No, I think that I would rather be kind of out there, combining science as well as interacting with people in the field.”

Q: When you started residency, was it clear to you that hospital medicine was where you wanted to go, or were you looking at a few different options?

A: Hospital medicine combined my interests in internal medicine, which is sort of a broad overview of all aspects of medicine and healthcare as well as being a little bit more intensive, a little bit more action-oriented. The patients tend to be a little bit more ill, require a little bit more acute attention, and that appealed to me as opposed to my training in internal medicine.

Q: What about the intensity of hospital medicine appeals to you?

A: As opposed to sitting down with a patient in an office setting, I think, in hospital medicine, I like the idea that you’re called from one semi-emergency to another and that you have to think quickly on your feet and move on to the new task. And the new tasks come in rapid sequence: You have one problem that you fix and then you’re called to do another one, and each and every day, it will tend to be sort of a different set of problems.

Q: What was the motivation to write the book and now working on the second?

A: I wanted to share my experience, and I felt I was in a position where I could not only share my personal practice experience as well as sort of collate the other material that has been written and published in hospital medicine. I also think there is a need right now to continue to define what hospital medicine is and show what we’re experts at as well as show our value to the system. We have an ambiguous practice, and people still aren’t quite sure what we do and what we’re expert at. So I think it’s our task to showcase this is what we do well, this is what we do better than other people, and this is our value to the system.

Q: So what is hospitalists’ value, and what are they experts in?

A: We’re experts at systems, hospital systems. … We understand better than anyone what goes on in the hospital, the physicians’ practice, the nursing practice, the administrative practice. … I mean, we’re there. We’re on the floors. No one has a better insight into the function of the hospital than the hospitalists. I think the other unique role we have is we see trends that other specialties don’t. We don’t really own our patients. Our patients come and go, but we tend to have a unique view of the practice of medicine that we see trends maybe before other specialists. … We see some of the failures of other systems.

Q: What is your least favorite part of being a hospitalist?

A: The clerical work. I think I probably speak for most people in that the clerical work is needed. It has become an increasing part of our practice in that now we spend a great deal of our time obviously in front of computers as opposed to at the bedside. The electronic medical record, which is good, which has served us well, becomes a greater and bigger part of our day, and so we find that it is too much a part of my day. I’m not saying it’s not needed because I think it has improved the quality of care we deliver, but it’s not something that you imagine that you should be doing as a physician. You are spending most of your day in front of a computer as opposed to most of the day with patients.

Q: What’s your favorite part of the job?

A: It has changed over my career. I think it probably started out in education. I enjoyed teaching medical students and residents, and certainly, that’s still a part of it, but then I think it has evolved into a little bit more of an academic interest. I just published my first book this past year and am working on my second book, and that has become sort of my bigger focus now. TH

Richard Quinn is a freelance writer in New Jersey.