SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

Brendon Shank is SHM’s associate vice president of communications.

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

Brendon Shank is SHM’s associate vice president of communications.

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

Brendon Shank is SHM’s associate vice president of communications.

President Obama has nominated 37-year-old Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has worked since 2006 as a hospitalist and assistant professor of medicine at Harvard Medical School and Brigham and Women’s Hospital in Boston. He is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.

If confirmed by the U.S. Senate, Dr. Murthy would replace acting surgeon general Boris Lushniak. The surgeon general serves a four-year term. “We share a belief that access to quality health care is a basic human right,” Brigham president Dr. Betsy Nabel said in a statement about Dr. Murthy. “I am confident that he will be a passionate advocate and that he will have an extraordinary impact as our nation’s surgeon general.”

Dr. Murthy studied at Harvard, received his medical degree at Yale School of Medicine, and earned an MBA from Yale School of Management. In 2011, he was appointed to serve as a member of the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. He was co-founder and is chairman of the board of TrialNetworks, formerly known as Epernicus, since 2007. He co-founded VISIONS Worldwide in 1995, a non-profit organization focused on HIV/AIDS education in India and the United States, where he served as president from 1995 to 2000 and chairman of the board from 2000 to 2003.

Daniel Virnich, MD, MBA, has been named TeamHealth Hospital Medicine’s new chief medical officer. Dr. Virnich previously served as the company’s western region medical director. He currently serves on SHM’s Practice Management Committee and SHM’s Patient Experience Task Force. TeamHealth, based in Knoxville, Tenn., provides private hospitalist services in 47 states.

Dean Dalili, MD, FHM, is the new vice president of medical affairs at Hollywood, Fla.-based Hospital Physician Partners (HPP), a private hospitalist management company with services in more than 20 states. Dr. Dalili previously served as HPP medical director and regional medical director. He was recognized in 2012 and this year as one of HPP’s outstanding medical directors in the hospital medicine division for his operational and leadership excellence.

David Roe is the new executive director of IPC The Hospitalist Company’s Northeast Tenn./Southwest Virginia region, where he will oversee operations at both acute and post-acute care facilities throughout the region. Roe previously served as executive director of THS Physician Partners, a multi-specialty physician group based in Charleston, W.Va.

Robert Mickelsen, MD, has been appointed system medical director for Lovelace Hospitalist Services in Albuquerque, N.M. The programs at Lovelace’s three hospital facilities are all managed by Hospital Physician Partners (HPP), and Dr. Mickelsen will be charged with overseeing operations at all three hospitals. Dr. Mickelsen comes to his new role from Gerald Champion Regional Medical Center in Alamogordo, N.M., where he served as hospitalist medical director.

Francisco Loya, MD, MSc, has been named chief medical officer for EmCare Hospital Medicine. Dr. Loya earned his medical degree at the University of Texas Southwestern Medical School in Dallas and completed his internal medicine residency at Brigham and Women’s Hospital in Boston. He earned his master of science degree in healthcare management from Harvard School of Public Health in Boston. After earning his master’s degree, Dr. Loya created a software tool (CMORx) that uses deductive algorithms to fill the gaps in medical records, which he will bring with him to EmCare. Based in Dallas, EmCare provides hospitalist and other services to more than 500 hospitals nationwide.

Business Moves

ECI Healthcare Partners, based in Traverse City, Mich., will now provide hospitalist services to O’Bleness Memorial Hospital in Athens, Ohio. O’Bleness Memorial has been serving the neighborhoods in and around Athens since 1921. ECI Healthcare Partners provides hospitalist and emergency medicine services to hospitals in more than 30 states.

Michael O’Neal is a freelance writer in New York City.

President Obama has nominated 37-year-old Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has worked since 2006 as a hospitalist and assistant professor of medicine at Harvard Medical School and Brigham and Women’s Hospital in Boston. He is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.

If confirmed by the U.S. Senate, Dr. Murthy would replace acting surgeon general Boris Lushniak. The surgeon general serves a four-year term. “We share a belief that access to quality health care is a basic human right,” Brigham president Dr. Betsy Nabel said in a statement about Dr. Murthy. “I am confident that he will be a passionate advocate and that he will have an extraordinary impact as our nation’s surgeon general.”

Dr. Murthy studied at Harvard, received his medical degree at Yale School of Medicine, and earned an MBA from Yale School of Management. In 2011, he was appointed to serve as a member of the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. He was co-founder and is chairman of the board of TrialNetworks, formerly known as Epernicus, since 2007. He co-founded VISIONS Worldwide in 1995, a non-profit organization focused on HIV/AIDS education in India and the United States, where he served as president from 1995 to 2000 and chairman of the board from 2000 to 2003.

Daniel Virnich, MD, MBA, has been named TeamHealth Hospital Medicine’s new chief medical officer. Dr. Virnich previously served as the company’s western region medical director. He currently serves on SHM’s Practice Management Committee and SHM’s Patient Experience Task Force. TeamHealth, based in Knoxville, Tenn., provides private hospitalist services in 47 states.

Dean Dalili, MD, FHM, is the new vice president of medical affairs at Hollywood, Fla.-based Hospital Physician Partners (HPP), a private hospitalist management company with services in more than 20 states. Dr. Dalili previously served as HPP medical director and regional medical director. He was recognized in 2012 and this year as one of HPP’s outstanding medical directors in the hospital medicine division for his operational and leadership excellence.

David Roe is the new executive director of IPC The Hospitalist Company’s Northeast Tenn./Southwest Virginia region, where he will oversee operations at both acute and post-acute care facilities throughout the region. Roe previously served as executive director of THS Physician Partners, a multi-specialty physician group based in Charleston, W.Va.

Robert Mickelsen, MD, has been appointed system medical director for Lovelace Hospitalist Services in Albuquerque, N.M. The programs at Lovelace’s three hospital facilities are all managed by Hospital Physician Partners (HPP), and Dr. Mickelsen will be charged with overseeing operations at all three hospitals. Dr. Mickelsen comes to his new role from Gerald Champion Regional Medical Center in Alamogordo, N.M., where he served as hospitalist medical director.

Francisco Loya, MD, MSc, has been named chief medical officer for EmCare Hospital Medicine. Dr. Loya earned his medical degree at the University of Texas Southwestern Medical School in Dallas and completed his internal medicine residency at Brigham and Women’s Hospital in Boston. He earned his master of science degree in healthcare management from Harvard School of Public Health in Boston. After earning his master’s degree, Dr. Loya created a software tool (CMORx) that uses deductive algorithms to fill the gaps in medical records, which he will bring with him to EmCare. Based in Dallas, EmCare provides hospitalist and other services to more than 500 hospitals nationwide.

Business Moves

ECI Healthcare Partners, based in Traverse City, Mich., will now provide hospitalist services to O’Bleness Memorial Hospital in Athens, Ohio. O’Bleness Memorial has been serving the neighborhoods in and around Athens since 1921. ECI Healthcare Partners provides hospitalist and emergency medicine services to hospitals in more than 30 states.

Michael O’Neal is a freelance writer in New York City.

President Obama has nominated 37-year-old Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has worked since 2006 as a hospitalist and assistant professor of medicine at Harvard Medical School and Brigham and Women’s Hospital in Boston. He is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.

If confirmed by the U.S. Senate, Dr. Murthy would replace acting surgeon general Boris Lushniak. The surgeon general serves a four-year term. “We share a belief that access to quality health care is a basic human right,” Brigham president Dr. Betsy Nabel said in a statement about Dr. Murthy. “I am confident that he will be a passionate advocate and that he will have an extraordinary impact as our nation’s surgeon general.”

Dr. Murthy studied at Harvard, received his medical degree at Yale School of Medicine, and earned an MBA from Yale School of Management. In 2011, he was appointed to serve as a member of the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. He was co-founder and is chairman of the board of TrialNetworks, formerly known as Epernicus, since 2007. He co-founded VISIONS Worldwide in 1995, a non-profit organization focused on HIV/AIDS education in India and the United States, where he served as president from 1995 to 2000 and chairman of the board from 2000 to 2003.

Daniel Virnich, MD, MBA, has been named TeamHealth Hospital Medicine’s new chief medical officer. Dr. Virnich previously served as the company’s western region medical director. He currently serves on SHM’s Practice Management Committee and SHM’s Patient Experience Task Force. TeamHealth, based in Knoxville, Tenn., provides private hospitalist services in 47 states.

Dean Dalili, MD, FHM, is the new vice president of medical affairs at Hollywood, Fla.-based Hospital Physician Partners (HPP), a private hospitalist management company with services in more than 20 states. Dr. Dalili previously served as HPP medical director and regional medical director. He was recognized in 2012 and this year as one of HPP’s outstanding medical directors in the hospital medicine division for his operational and leadership excellence.

David Roe is the new executive director of IPC The Hospitalist Company’s Northeast Tenn./Southwest Virginia region, where he will oversee operations at both acute and post-acute care facilities throughout the region. Roe previously served as executive director of THS Physician Partners, a multi-specialty physician group based in Charleston, W.Va.

Robert Mickelsen, MD, has been appointed system medical director for Lovelace Hospitalist Services in Albuquerque, N.M. The programs at Lovelace’s three hospital facilities are all managed by Hospital Physician Partners (HPP), and Dr. Mickelsen will be charged with overseeing operations at all three hospitals. Dr. Mickelsen comes to his new role from Gerald Champion Regional Medical Center in Alamogordo, N.M., where he served as hospitalist medical director.

Francisco Loya, MD, MSc, has been named chief medical officer for EmCare Hospital Medicine. Dr. Loya earned his medical degree at the University of Texas Southwestern Medical School in Dallas and completed his internal medicine residency at Brigham and Women’s Hospital in Boston. He earned his master of science degree in healthcare management from Harvard School of Public Health in Boston. After earning his master’s degree, Dr. Loya created a software tool (CMORx) that uses deductive algorithms to fill the gaps in medical records, which he will bring with him to EmCare. Based in Dallas, EmCare provides hospitalist and other services to more than 500 hospitals nationwide.

Business Moves

ECI Healthcare Partners, based in Traverse City, Mich., will now provide hospitalist services to O’Bleness Memorial Hospital in Athens, Ohio. O’Bleness Memorial has been serving the neighborhoods in and around Athens since 1921. ECI Healthcare Partners provides hospitalist and emergency medicine services to hospitals in more than 30 states.

Michael O’Neal is a freelance writer in New York City.

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says.

Tom Collins is a freelance writer in South Florida.

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says.

Tom Collins is a freelance writer in South Florida.

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says.

Tom Collins is a freelance writer in South Florida.

Dr. Danella

10 Things: At A Glance

1. Take out urinary catheters as soon as possible.
2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
3. Beware certain types of medications in vulnerable patients.
4. Don’t discharge patients who are having difficulty voiding.
5. Broach sensitive topics, but do so gently.
6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
7. Diabetic patients require extra attention.
8. Practice good antibiotic stewardship.
9. Determine whether the patient can be seen as an outpatient.
10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.¹

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”²

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.³

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”

Tom Collins is a freelance writer in South Florida.

References

1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

Dr. Danella

10 Things: At A Glance

1. Take out urinary catheters as soon as possible.
2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
3. Beware certain types of medications in vulnerable patients.
4. Don’t discharge patients who are having difficulty voiding.
5. Broach sensitive topics, but do so gently.
6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
7. Diabetic patients require extra attention.
8. Practice good antibiotic stewardship.
9. Determine whether the patient can be seen as an outpatient.
10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.¹

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”²

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.³

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”

Tom Collins is a freelance writer in South Florida.

References

1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

Dr. Danella

10 Things: At A Glance

1. Take out urinary catheters as soon as possible.
2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
3. Beware certain types of medications in vulnerable patients.
4. Don’t discharge patients who are having difficulty voiding.
5. Broach sensitive topics, but do so gently.
6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
7. Diabetic patients require extra attention.
8. Practice good antibiotic stewardship.
9. Determine whether the patient can be seen as an outpatient.
10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.¹

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”²

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.³

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”

Tom Collins is a freelance writer in South Florida.

References

1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

Palliative care increasingly is the subject of clinical and administrative research in medical literature, with investigators examining its impact on costs and utilization of hospital care and other health services, as well as on such outcomes as pain and symptom management and patient and family satisfaction with health services.

An influential study of cost savings associated with hospital palliative care consultation services, conducted by R. Sean Morrison, MD, and colleagues at the National Palliative Care Research Center at Mount Sinai School of Medicine in New York City, matched 2,630 palliative care patients to 18,472 “usual care patients” and concluded that the cost savings averaged $4,988 per patient in direct costs per day for those dying in the hospital.³ A follow-up study in 2010 confirmed these results, and Dr. Morrison and colleagues have documented improved quality from palliative care based on a survey of bereaved family members of patients who received palliative care.^4,5

A 2010 study by a group at Massachusetts General Hospital, led by Jennifer Temel, MD, reached the surprising conclusion that early palliative care for patients with metastatic non-small-cell lung cancer led not only to significant improvements in quality of life and mood and less provision of aggressive care at the end of life—but also to longer survival.⁶ The researchers have studied possible mechanisms for this result, as well as the integration of palliative care with oncology and the importance of palliative care support provided outside of the hospital, in community-based and outpatient settings. ^7,8,9

Community-based palliative care is a significant new direction for palliative care in America, and the availability of palliative care outside of the hospital’s four walls is viewed as important to improving care transitions and preventing readmissions in the seriously ill patients typically targeted for palliative care. The effects of palliative care on 30-day readmissions rates was studied by Susan Enguidanos, PhD, MPH, and colleagues at the University of Southern California School of Gerontology; they found that receipt of palliative care following hospital discharge were a significant factor in reducing 30-day rehospitalizations.¹⁰

A study from Albert Einstein College of Medicine in New York explored outcomes from a dedicated acute palliative care unit in an academic medical center, while others have looked at the diverse landscape of palliative care in outpatient clinics and its potential for rapid growth.^11,12

—Larry Beresford

References

1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

Palliative care increasingly is the subject of clinical and administrative research in medical literature, with investigators examining its impact on costs and utilization of hospital care and other health services, as well as on such outcomes as pain and symptom management and patient and family satisfaction with health services.

An influential study of cost savings associated with hospital palliative care consultation services, conducted by R. Sean Morrison, MD, and colleagues at the National Palliative Care Research Center at Mount Sinai School of Medicine in New York City, matched 2,630 palliative care patients to 18,472 “usual care patients” and concluded that the cost savings averaged $4,988 per patient in direct costs per day for those dying in the hospital.³ A follow-up study in 2010 confirmed these results, and Dr. Morrison and colleagues have documented improved quality from palliative care based on a survey of bereaved family members of patients who received palliative care.^4,5

A 2010 study by a group at Massachusetts General Hospital, led by Jennifer Temel, MD, reached the surprising conclusion that early palliative care for patients with metastatic non-small-cell lung cancer led not only to significant improvements in quality of life and mood and less provision of aggressive care at the end of life—but also to longer survival.⁶ The researchers have studied possible mechanisms for this result, as well as the integration of palliative care with oncology and the importance of palliative care support provided outside of the hospital, in community-based and outpatient settings. ^7,8,9

Community-based palliative care is a significant new direction for palliative care in America, and the availability of palliative care outside of the hospital’s four walls is viewed as important to improving care transitions and preventing readmissions in the seriously ill patients typically targeted for palliative care. The effects of palliative care on 30-day readmissions rates was studied by Susan Enguidanos, PhD, MPH, and colleagues at the University of Southern California School of Gerontology; they found that receipt of palliative care following hospital discharge were a significant factor in reducing 30-day rehospitalizations.¹⁰

A study from Albert Einstein College of Medicine in New York explored outcomes from a dedicated acute palliative care unit in an academic medical center, while others have looked at the diverse landscape of palliative care in outpatient clinics and its potential for rapid growth.^11,12

—Larry Beresford

References

1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

Palliative care increasingly is the subject of clinical and administrative research in medical literature, with investigators examining its impact on costs and utilization of hospital care and other health services, as well as on such outcomes as pain and symptom management and patient and family satisfaction with health services.

An influential study of cost savings associated with hospital palliative care consultation services, conducted by R. Sean Morrison, MD, and colleagues at the National Palliative Care Research Center at Mount Sinai School of Medicine in New York City, matched 2,630 palliative care patients to 18,472 “usual care patients” and concluded that the cost savings averaged $4,988 per patient in direct costs per day for those dying in the hospital.³ A follow-up study in 2010 confirmed these results, and Dr. Morrison and colleagues have documented improved quality from palliative care based on a survey of bereaved family members of patients who received palliative care.^4,5

A 2010 study by a group at Massachusetts General Hospital, led by Jennifer Temel, MD, reached the surprising conclusion that early palliative care for patients with metastatic non-small-cell lung cancer led not only to significant improvements in quality of life and mood and less provision of aggressive care at the end of life—but also to longer survival.⁶ The researchers have studied possible mechanisms for this result, as well as the integration of palliative care with oncology and the importance of palliative care support provided outside of the hospital, in community-based and outpatient settings. ^7,8,9

Community-based palliative care is a significant new direction for palliative care in America, and the availability of palliative care outside of the hospital’s four walls is viewed as important to improving care transitions and preventing readmissions in the seriously ill patients typically targeted for palliative care. The effects of palliative care on 30-day readmissions rates was studied by Susan Enguidanos, PhD, MPH, and colleagues at the University of Southern California School of Gerontology; they found that receipt of palliative care following hospital discharge were a significant factor in reducing 30-day rehospitalizations.¹⁰

A study from Albert Einstein College of Medicine in New York explored outcomes from a dedicated acute palliative care unit in an academic medical center, while others have looked at the diverse landscape of palliative care in outpatient clinics and its potential for rapid growth.^11,12

—Larry Beresford

References

1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

Valerie Phillips was diagnosed with stage IV breast cancer in 2010 and is a shining example of the difference a palliative care consultation can make. After she was diagnosed, the Austin, Texas, native continued to work and enjoy a relatively normal life. But when the disease metastasized to her hip, she began to take opioid analgesics for the pain.

Phillips says she felt foolish when she ended up in the ED, profoundly uncomfortable from a four-day impaction due to the analgesic and oral cancer drugs. “But nobody told me about all that,” she says.

She thinks her oncologist was giving good care, “but her area was treating the disease.”

Upon admission, a hospitalist referred Phillips for an inpatient palliative care consultation with Stephen Bekanich, MD, a former hospitalist who now co-directs Seton Palliative Care for the Seton Health System in Austin.

“I learned there’s a big difference between fighting the disease and treating the needs of the patient as a person,” Phillips explains. “A palliative care doctor like Stephen changes everything. He found a way for me to better navigate the healthcare system, carrying all of that information in his head. He said to me, ‘OK, we’re going to make sure this doesn’t happen again.’

I trusted him—and it worked.” Phillips says she understands that her long-term prospects aren’t great, and she expects to enroll in hospice soon. She hasn’t been back to the hospital, but has continued to see Dr. Bekanich as an outpatient.

“For me, there was an informational and educational gap, and I have a master’s degree and a career in management,” she says. “Stephen was able to tie everything together for me.”

Phillips says hospitalists should focus on the connection between disease treatment and the quality of life palliative care affords. “They should go hand in hand. Patients should be able to count on somebody who can take us by the hand and make the whole process as painless—and worry-free—as possible.”

—Larry Beresford

Valerie Phillips was diagnosed with stage IV breast cancer in 2010 and is a shining example of the difference a palliative care consultation can make. After she was diagnosed, the Austin, Texas, native continued to work and enjoy a relatively normal life. But when the disease metastasized to her hip, she began to take opioid analgesics for the pain.

Phillips says she felt foolish when she ended up in the ED, profoundly uncomfortable from a four-day impaction due to the analgesic and oral cancer drugs. “But nobody told me about all that,” she says.

She thinks her oncologist was giving good care, “but her area was treating the disease.”

Upon admission, a hospitalist referred Phillips for an inpatient palliative care consultation with Stephen Bekanich, MD, a former hospitalist who now co-directs Seton Palliative Care for the Seton Health System in Austin.

“I learned there’s a big difference between fighting the disease and treating the needs of the patient as a person,” Phillips explains. “A palliative care doctor like Stephen changes everything. He found a way for me to better navigate the healthcare system, carrying all of that information in his head. He said to me, ‘OK, we’re going to make sure this doesn’t happen again.’

I trusted him—and it worked.” Phillips says she understands that her long-term prospects aren’t great, and she expects to enroll in hospice soon. She hasn’t been back to the hospital, but has continued to see Dr. Bekanich as an outpatient.

“For me, there was an informational and educational gap, and I have a master’s degree and a career in management,” she says. “Stephen was able to tie everything together for me.”

Phillips says hospitalists should focus on the connection between disease treatment and the quality of life palliative care affords. “They should go hand in hand. Patients should be able to count on somebody who can take us by the hand and make the whole process as painless—and worry-free—as possible.”

—Larry Beresford

Valerie Phillips was diagnosed with stage IV breast cancer in 2010 and is a shining example of the difference a palliative care consultation can make. After she was diagnosed, the Austin, Texas, native continued to work and enjoy a relatively normal life. But when the disease metastasized to her hip, she began to take opioid analgesics for the pain.

Phillips says she felt foolish when she ended up in the ED, profoundly uncomfortable from a four-day impaction due to the analgesic and oral cancer drugs. “But nobody told me about all that,” she says.

She thinks her oncologist was giving good care, “but her area was treating the disease.”

Upon admission, a hospitalist referred Phillips for an inpatient palliative care consultation with Stephen Bekanich, MD, a former hospitalist who now co-directs Seton Palliative Care for the Seton Health System in Austin.

“I learned there’s a big difference between fighting the disease and treating the needs of the patient as a person,” Phillips explains. “A palliative care doctor like Stephen changes everything. He found a way for me to better navigate the healthcare system, carrying all of that information in his head. He said to me, ‘OK, we’re going to make sure this doesn’t happen again.’

I trusted him—and it worked.” Phillips says she understands that her long-term prospects aren’t great, and she expects to enroll in hospice soon. She hasn’t been back to the hospital, but has continued to see Dr. Bekanich as an outpatient.

“For me, there was an informational and educational gap, and I have a master’s degree and a career in management,” she says. “Stephen was able to tie everything together for me.”

Phillips says hospitalists should focus on the connection between disease treatment and the quality of life palliative care affords. “They should go hand in hand. Patients should be able to count on somebody who can take us by the hand and make the whole process as painless—and worry-free—as possible.”

—Larry Beresford

Dr. Bekanich

Dr. Bekanich

After nine years in practice as a hospitalist in community and academic settings, Leonard Noronha, MD, applied for and in July 2012 became the inaugural, full-year, full-time fellow in hospice and palliative medicine (HPM) at the University of New Mexico in Albuquerque, one of approximately 200 such positions nationwide. The fellowship training qualifies him to sit for HPM subspecialty medical board certification.

Dr. Noronha says he was casually acquainted with the concept of palliative care from residency but didn’t know “when to ask for a palliative care consultation or what they offered.”

“I also had a sense that discussions about feeding tubes, for example, could happen better and easier than they typically did,” he says.

His interest piqued as he learned more about palliative care at hospitalist meetings.

“I grew more excited about it and came to realize that it is something I’d find rewarding and enjoyable, if I could get good at it,” Dr. Noronha says. “Over time, I found more satisfaction in palliative care encounters with patients—and became less comfortable with what I perceived as occasionally inappropriate and excessive testing and treatment [for some hospitalized patients who weren’t offered palliative care].”

Palliative care is a medical specialty that focuses on comfort, relief of symptoms, and clarifying patients’ treatment goals. It is commonly provided as an interdisciplinary consultation service in hospitals. Advocates say it can be offered concurrently with other medical therapies for any seriously ill patient, particularly when there are physical, psychosocial, or spiritual complications, and it is not limited to patients approaching death.

Experienced clinicians say palliative care maximizes quality of life and empowers patients and their families to make treatment decisions more in line with their hopes and values. They also say palliative care gives an emotional lift to providers, while reducing hospital expenditures. Some also suggest that palliative care is an additional tool for enhancing care transitions, potentially affecting readmission rates.

For Dr. Noronha, the one-year fellowship required a significant cut in pay, but he was prepared for the financial hardship.

“It was a great decision for me,” he says. “Some of my colleagues had encouraged me to think about using the experiential pathway to HPM board certification, but I knew I’d do better in the structured environment of a fellowship.

“There have been times when I’ve been outside of my comfort zone, sometimes feeling like the least experienced person in the room. But I knew the fellowship would help—and it did.”

He says the training gives him a better appreciation for things like illness trajectories, the nuances of goal clarification, and the benefit of an extra set of eyes and ears to assess the patient.

After completing his fellowship, Dr. Noronha became UNM’s second full-time palliative medicine faculty. He encourages hospitalists to talk to the palliative care service at their institutions and request consultations for complex, seriously ill patients who might benefit.

As for his new career path, he says that often he is asked if palliative care is depressing. “Some of these situations can be tragic, but I find the work very rewarding,” he says.

Service Models

In some settings, palliative care is incorporated into the hospitalist service. Hospitalists are scheduled for palliative care shifts or have palliative care visits incorporated into daily rounds. Such blended positions could be a recruiting incentive for some physicians who want to do both.

In other settings, palliative care is a separate service. Consultations are ordered as needed by hospitalists and other physicians.

Advocates like Marianne Novelli, MD, FHM, FACP, say hospitalists play a pivotal role in providing the basics of palliative care for seriously ill, hospitalized patients.

“Palliative care is part and parcel of what we do as hospitalists with the people we serve—who by definition are very sick, even to get into the hospital,” says Dr. Novelli, formerly the chief of the division of hospital medicine at Kaiser Permanente in Denver, Colo. She rotated off that leadership position in 2011 and has since divided her time between hospital medicine and palliative care shifts in the hospital, although she now does palliative care exclusively.

Initially, she watched palliative care consults and asked for mentorship from the palliative care team. Although it took time to get used to the advisory role of the consultant, and to working with a team, she eventually became board certified in HPM.

“Palliative care is incredibly intense but richly rewarding work,” she says. “The patients you see are never simple. It allows us to practice the type of medicine we originally set out to do, with people at the most vulnerable times in their lives.”

Workforce, Fellowship, Board Certification

In October 2012, 3,356 physicians passed the hospice and palliative medicine subspecialty board exams offered by the American Board of Medical Specialties and 10 of its constituent specialty boards, with the lion’s share of them certified by the American Board of Internal Medicine. That more than doubled the number of physicians earning the HPM credential since its inception in 2008.

Even with the surge in palliative care training, workforce studies suggest the U.S. is woefully short of credentialed palliative care physicians. And many think hospitalists can help fill that void.

The Center to Advance Palliative Care (CAPC, www.capc.org) counts 1,400 hospital-based palliative care programs in the U.S., while the Centers for Medicare & Medicaid Services (CMS) recognizes about 3,500 Medicare-certified hospice programs. A 2010 estimate by Dale Lupu and the American Academy of Hospice and Palliative Medicine (AAHPM), however, suggested a need for between 4,487 and 10,810 palliative care physician FTEs just to staff existing programs at appropriate levels—without considering growth for the field or its spread into outpatient settings.¹

In the past, mid-career physicians had an experiential pathway to the HPM board exam, based on hours worked with a hospice or palliative care team, but physicians now must complete an HPM fellowship of at least one year in order to sit for the boards. And, according to AAHPM, only 234 HPM fellowship positions are offered nationwide by 85 approved fellowship programs.

Dr. Bekanich

A one-year fellowship is a big commitment for an established hospitalist, according to Stephen Bekanich, MD, co-director of Seton Palliative Care at Seton Healthcare, an 11-hospital system in Austin, Texas. A former hospitalist, Dr. Bekanich says that in his region a fellow stipend is about $70,000, whereas typical hospitalist compensation is in the mid- to upper-$200,000s.

AAHPM is exploring other approaches to expanding the workforce with mid-career physicians. One approach, authored by Timothy Quill, MD, and Amy Abernethy, MD, the past and current AAHPM board presidents, is to develop a two-tiered system in which palliative medicine specialists teach basic palliative care techniques and approaches to primary care physicians, hospitalists, and such specialists as oncologists.² The article also suggested equipping clinicians with the tools to recognize when more specialized help is needed.

“As in any medical discipline, some core elements of palliative care, such as aligning treatment with a patient’s goals and basic symptom management, should be routine aspects of care delivered by any practitioner,” Drs. Quill and Abernethy wrote. “Other skills are more complex and take years of training to learn and apply, such as negotiating a difficult family meeting, addressing veiled existential distress, and managing refractory symptoms.”

Dr. Bekanich is trying the two-tiered approach at Seton Healthcare. At facilities with no palliative care service, he is transplanting palliative-trained nurse practitioners in hospital medicine groups.

“This model is locked into our budget for fiscal year 2014,” Dr. Bekanich says. “We’ll train folks, starting with hospitalists and primary care physicians.”

The training will start with a pair of three-hour sessions on palliative care techniques for hospitalists and PCPs, followed by homework assignments. “Then we’ll meet again in three months to do some role plays,” he says.

Two final rounds of training will focus on skills, philosophy, values, and practice.

Palliative care is incredibly intense but richly rewarding work. The patients you see are never simple. It allows us to practice the type of medicine we originally set out to do, with people at the most vulnerable times in their lives.

—Marianne Novelli, MD, FHM, FACP, former chief of the division of hospital medicine, Kaiser Permanente, Denver, Colo.

On-the-Job Training

David Weissman, MD, FACP, a palliative care specialist in Milwaukee, Wis., and consultant to the CAPC, recommends hospitalists do what they can to improve their knowledge and skills. “There are a lot of opportunities for palliative care training out there,” he says.

HM conferences often include palliative care content. AAHPM and CAPC offer annual conferences that immerse participants in content, with opportunities to mingle with palliative care colleagues. AAHPM also offers specific content through its “Unipac” series of nine self-study training modules (www.aahpm.org/resources/default/unipac-4th-edition.html.)

Dr. Weissman

On the job, Dr. Weissman says hospitalists should ask for consults for patients with complex needs. Also pay attention to how the service works and what it recommends. Taking a couple of days to round with the palliative care service could be very educational. It may be possible to take a part-time position with the team, providing weekend or vacation coverage. Hospitalists can participate on planning or advisory committees for palliative care in their hospitals or on quality improvement projects.

“If there isn’t a palliative care service, advocate for developing one,” he says.

Local hospice programs, especially those with inpatient hospice facilities that need daily physician coverage, might have part-time staff positions, which could be a great moonlighting opportunity for hospitalists and a way to learn a lot very quickly.

“I can tell the difference between physicians who have spent time working in a hospice, where you can learn about caring for people at the end of life because most of the patients are so sick, and those who have not,” says Porter Storey, MD, FACP, AAHPM’s executive vice president and a practicing palliative care physician in Colorado. “You can learn how to use the medications to get someone comfortable quickly and how to talk to families in crisis. It can be some of the most rewarding work you can possibly do—especially when you have the time and training to do it well for some of the most challenging of patients and families.”

Dr. Storey recommends that hospitalists join AAHPM, use its professional materials, attend its annual meetings, and, if they feel a calling, consider fellowship training as the next big step.

“Palliative care programs are growing in number and size but are chronically understaffed,” says Steven Pantilat, MD, SFHM, hospitalist and director of the Palliative Care Program at the University of California at San Francisco. “This creates a great opportunity for hospitalists. I have heard of places that were having trouble recruiting palliative care physicians but were willing to sponsor a hospitalist to go and do a fellowship, supplementing their salary as an incentive—and a reasonable one—for a hospitalist interested in making a career move.”

He says that palliative care, like hospital medicine, has been a significant value-add in many hospitals and health systems. More importantly, it correlates to positive patient outcomes (see “Research Highlights Palliative Care Contributions,”).

Dr. Pantilat

“What’s new is how it connects to current issues like improved care transitions and readmissions reduction,” Dr. Pantilat says.

Advocates say palliative care helps to match medical services to patient preferences, thereby improving patient satisfaction scores, especially for those who aren’t likely to achieve good outcomes. Dr. Pantilat says it puts plans in place for patients to get the right services for the post-discharge period and for responding to anticipated problems like chest pain.

“It’s not just how to get patients out of the hospital as quickly as possible,” he says, “but to do that with a plan that sets them up to succeed at home.”

Larry Beresford is a freelance writer in San Francisco.

References

1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

Dr. Bekanich

Dr. Bekanich

After nine years in practice as a hospitalist in community and academic settings, Leonard Noronha, MD, applied for and in July 2012 became the inaugural, full-year, full-time fellow in hospice and palliative medicine (HPM) at the University of New Mexico in Albuquerque, one of approximately 200 such positions nationwide. The fellowship training qualifies him to sit for HPM subspecialty medical board certification.

Dr. Noronha says he was casually acquainted with the concept of palliative care from residency but didn’t know “when to ask for a palliative care consultation or what they offered.”

“I also had a sense that discussions about feeding tubes, for example, could happen better and easier than they typically did,” he says.

His interest piqued as he learned more about palliative care at hospitalist meetings.

“I grew more excited about it and came to realize that it is something I’d find rewarding and enjoyable, if I could get good at it,” Dr. Noronha says. “Over time, I found more satisfaction in palliative care encounters with patients—and became less comfortable with what I perceived as occasionally inappropriate and excessive testing and treatment [for some hospitalized patients who weren’t offered palliative care].”

Palliative care is a medical specialty that focuses on comfort, relief of symptoms, and clarifying patients’ treatment goals. It is commonly provided as an interdisciplinary consultation service in hospitals. Advocates say it can be offered concurrently with other medical therapies for any seriously ill patient, particularly when there are physical, psychosocial, or spiritual complications, and it is not limited to patients approaching death.

Experienced clinicians say palliative care maximizes quality of life and empowers patients and their families to make treatment decisions more in line with their hopes and values. They also say palliative care gives an emotional lift to providers, while reducing hospital expenditures. Some also suggest that palliative care is an additional tool for enhancing care transitions, potentially affecting readmission rates.

For Dr. Noronha, the one-year fellowship required a significant cut in pay, but he was prepared for the financial hardship.

“It was a great decision for me,” he says. “Some of my colleagues had encouraged me to think about using the experiential pathway to HPM board certification, but I knew I’d do better in the structured environment of a fellowship.

“There have been times when I’ve been outside of my comfort zone, sometimes feeling like the least experienced person in the room. But I knew the fellowship would help—and it did.”

He says the training gives him a better appreciation for things like illness trajectories, the nuances of goal clarification, and the benefit of an extra set of eyes and ears to assess the patient.

After completing his fellowship, Dr. Noronha became UNM’s second full-time palliative medicine faculty. He encourages hospitalists to talk to the palliative care service at their institutions and request consultations for complex, seriously ill patients who might benefit.

As for his new career path, he says that often he is asked if palliative care is depressing. “Some of these situations can be tragic, but I find the work very rewarding,” he says.

Service Models

In some settings, palliative care is incorporated into the hospitalist service. Hospitalists are scheduled for palliative care shifts or have palliative care visits incorporated into daily rounds. Such blended positions could be a recruiting incentive for some physicians who want to do both.

In other settings, palliative care is a separate service. Consultations are ordered as needed by hospitalists and other physicians.

Advocates like Marianne Novelli, MD, FHM, FACP, say hospitalists play a pivotal role in providing the basics of palliative care for seriously ill, hospitalized patients.

“Palliative care is part and parcel of what we do as hospitalists with the people we serve—who by definition are very sick, even to get into the hospital,” says Dr. Novelli, formerly the chief of the division of hospital medicine at Kaiser Permanente in Denver, Colo. She rotated off that leadership position in 2011 and has since divided her time between hospital medicine and palliative care shifts in the hospital, although she now does palliative care exclusively.

Initially, she watched palliative care consults and asked for mentorship from the palliative care team. Although it took time to get used to the advisory role of the consultant, and to working with a team, she eventually became board certified in HPM.

“Palliative care is incredibly intense but richly rewarding work,” she says. “The patients you see are never simple. It allows us to practice the type of medicine we originally set out to do, with people at the most vulnerable times in their lives.”

Workforce, Fellowship, Board Certification

In October 2012, 3,356 physicians passed the hospice and palliative medicine subspecialty board exams offered by the American Board of Medical Specialties and 10 of its constituent specialty boards, with the lion’s share of them certified by the American Board of Internal Medicine. That more than doubled the number of physicians earning the HPM credential since its inception in 2008.

Even with the surge in palliative care training, workforce studies suggest the U.S. is woefully short of credentialed palliative care physicians. And many think hospitalists can help fill that void.

The Center to Advance Palliative Care (CAPC, www.capc.org) counts 1,400 hospital-based palliative care programs in the U.S., while the Centers for Medicare & Medicaid Services (CMS) recognizes about 3,500 Medicare-certified hospice programs. A 2010 estimate by Dale Lupu and the American Academy of Hospice and Palliative Medicine (AAHPM), however, suggested a need for between 4,487 and 10,810 palliative care physician FTEs just to staff existing programs at appropriate levels—without considering growth for the field or its spread into outpatient settings.¹

In the past, mid-career physicians had an experiential pathway to the HPM board exam, based on hours worked with a hospice or palliative care team, but physicians now must complete an HPM fellowship of at least one year in order to sit for the boards. And, according to AAHPM, only 234 HPM fellowship positions are offered nationwide by 85 approved fellowship programs.

Dr. Bekanich

A one-year fellowship is a big commitment for an established hospitalist, according to Stephen Bekanich, MD, co-director of Seton Palliative Care at Seton Healthcare, an 11-hospital system in Austin, Texas. A former hospitalist, Dr. Bekanich says that in his region a fellow stipend is about $70,000, whereas typical hospitalist compensation is in the mid- to upper-$200,000s.

AAHPM is exploring other approaches to expanding the workforce with mid-career physicians. One approach, authored by Timothy Quill, MD, and Amy Abernethy, MD, the past and current AAHPM board presidents, is to develop a two-tiered system in which palliative medicine specialists teach basic palliative care techniques and approaches to primary care physicians, hospitalists, and such specialists as oncologists.² The article also suggested equipping clinicians with the tools to recognize when more specialized help is needed.

“As in any medical discipline, some core elements of palliative care, such as aligning treatment with a patient’s goals and basic symptom management, should be routine aspects of care delivered by any practitioner,” Drs. Quill and Abernethy wrote. “Other skills are more complex and take years of training to learn and apply, such as negotiating a difficult family meeting, addressing veiled existential distress, and managing refractory symptoms.”

Dr. Bekanich is trying the two-tiered approach at Seton Healthcare. At facilities with no palliative care service, he is transplanting palliative-trained nurse practitioners in hospital medicine groups.

“This model is locked into our budget for fiscal year 2014,” Dr. Bekanich says. “We’ll train folks, starting with hospitalists and primary care physicians.”

The training will start with a pair of three-hour sessions on palliative care techniques for hospitalists and PCPs, followed by homework assignments. “Then we’ll meet again in three months to do some role plays,” he says.

Two final rounds of training will focus on skills, philosophy, values, and practice.

Palliative care is incredibly intense but richly rewarding work. The patients you see are never simple. It allows us to practice the type of medicine we originally set out to do, with people at the most vulnerable times in their lives.

—Marianne Novelli, MD, FHM, FACP, former chief of the division of hospital medicine, Kaiser Permanente, Denver, Colo.

On-the-Job Training

David Weissman, MD, FACP, a palliative care specialist in Milwaukee, Wis., and consultant to the CAPC, recommends hospitalists do what they can to improve their knowledge and skills. “There are a lot of opportunities for palliative care training out there,” he says.

HM conferences often include palliative care content. AAHPM and CAPC offer annual conferences that immerse participants in content, with opportunities to mingle with palliative care colleagues. AAHPM also offers specific content through its “Unipac” series of nine self-study training modules (www.aahpm.org/resources/default/unipac-4th-edition.html.)

Dr. Weissman

On the job, Dr. Weissman says hospitalists should ask for consults for patients with complex needs. Also pay attention to how the service works and what it recommends. Taking a couple of days to round with the palliative care service could be very educational. It may be possible to take a part-time position with the team, providing weekend or vacation coverage. Hospitalists can participate on planning or advisory committees for palliative care in their hospitals or on quality improvement projects.

“If there isn’t a palliative care service, advocate for developing one,” he says.

Local hospice programs, especially those with inpatient hospice facilities that need daily physician coverage, might have part-time staff positions, which could be a great moonlighting opportunity for hospitalists and a way to learn a lot very quickly.

“I can tell the difference between physicians who have spent time working in a hospice, where you can learn about caring for people at the end of life because most of the patients are so sick, and those who have not,” says Porter Storey, MD, FACP, AAHPM’s executive vice president and a practicing palliative care physician in Colorado. “You can learn how to use the medications to get someone comfortable quickly and how to talk to families in crisis. It can be some of the most rewarding work you can possibly do—especially when you have the time and training to do it well for some of the most challenging of patients and families.”

Dr. Storey recommends that hospitalists join AAHPM, use its professional materials, attend its annual meetings, and, if they feel a calling, consider fellowship training as the next big step.

“Palliative care programs are growing in number and size but are chronically understaffed,” says Steven Pantilat, MD, SFHM, hospitalist and director of the Palliative Care Program at the University of California at San Francisco. “This creates a great opportunity for hospitalists. I have heard of places that were having trouble recruiting palliative care physicians but were willing to sponsor a hospitalist to go and do a fellowship, supplementing their salary as an incentive—and a reasonable one—for a hospitalist interested in making a career move.”

He says that palliative care, like hospital medicine, has been a significant value-add in many hospitals and health systems. More importantly, it correlates to positive patient outcomes (see “Research Highlights Palliative Care Contributions,”).

Dr. Pantilat

“What’s new is how it connects to current issues like improved care transitions and readmissions reduction,” Dr. Pantilat says.

Advocates say palliative care helps to match medical services to patient preferences, thereby improving patient satisfaction scores, especially for those who aren’t likely to achieve good outcomes. Dr. Pantilat says it puts plans in place for patients to get the right services for the post-discharge period and for responding to anticipated problems like chest pain.

“It’s not just how to get patients out of the hospital as quickly as possible,” he says, “but to do that with a plan that sets them up to succeed at home.”

Larry Beresford is a freelance writer in San Francisco.

References

1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

Dr. Bekanich

Dr. Bekanich

After nine years in practice as a hospitalist in community and academic settings, Leonard Noronha, MD, applied for and in July 2012 became the inaugural, full-year, full-time fellow in hospice and palliative medicine (HPM) at the University of New Mexico in Albuquerque, one of approximately 200 such positions nationwide. The fellowship training qualifies him to sit for HPM subspecialty medical board certification.

Dr. Noronha says he was casually acquainted with the concept of palliative care from residency but didn’t know “when to ask for a palliative care consultation or what they offered.”

“I also had a sense that discussions about feeding tubes, for example, could happen better and easier than they typically did,” he says.

His interest piqued as he learned more about palliative care at hospitalist meetings.

“I grew more excited about it and came to realize that it is something I’d find rewarding and enjoyable, if I could get good at it,” Dr. Noronha says. “Over time, I found more satisfaction in palliative care encounters with patients—and became less comfortable with what I perceived as occasionally inappropriate and excessive testing and treatment [for some hospitalized patients who weren’t offered palliative care].”

Palliative care is a medical specialty that focuses on comfort, relief of symptoms, and clarifying patients’ treatment goals. It is commonly provided as an interdisciplinary consultation service in hospitals. Advocates say it can be offered concurrently with other medical therapies for any seriously ill patient, particularly when there are physical, psychosocial, or spiritual complications, and it is not limited to patients approaching death.

Experienced clinicians say palliative care maximizes quality of life and empowers patients and their families to make treatment decisions more in line with their hopes and values. They also say palliative care gives an emotional lift to providers, while reducing hospital expenditures. Some also suggest that palliative care is an additional tool for enhancing care transitions, potentially affecting readmission rates.

For Dr. Noronha, the one-year fellowship required a significant cut in pay, but he was prepared for the financial hardship.

“It was a great decision for me,” he says. “Some of my colleagues had encouraged me to think about using the experiential pathway to HPM board certification, but I knew I’d do better in the structured environment of a fellowship.

“There have been times when I’ve been outside of my comfort zone, sometimes feeling like the least experienced person in the room. But I knew the fellowship would help—and it did.”

He says the training gives him a better appreciation for things like illness trajectories, the nuances of goal clarification, and the benefit of an extra set of eyes and ears to assess the patient.

After completing his fellowship, Dr. Noronha became UNM’s second full-time palliative medicine faculty. He encourages hospitalists to talk to the palliative care service at their institutions and request consultations for complex, seriously ill patients who might benefit.

As for his new career path, he says that often he is asked if palliative care is depressing. “Some of these situations can be tragic, but I find the work very rewarding,” he says.

Service Models

In some settings, palliative care is incorporated into the hospitalist service. Hospitalists are scheduled for palliative care shifts or have palliative care visits incorporated into daily rounds. Such blended positions could be a recruiting incentive for some physicians who want to do both.

In other settings, palliative care is a separate service. Consultations are ordered as needed by hospitalists and other physicians.

Advocates like Marianne Novelli, MD, FHM, FACP, say hospitalists play a pivotal role in providing the basics of palliative care for seriously ill, hospitalized patients.

“Palliative care is part and parcel of what we do as hospitalists with the people we serve—who by definition are very sick, even to get into the hospital,” says Dr. Novelli, formerly the chief of the division of hospital medicine at Kaiser Permanente in Denver, Colo. She rotated off that leadership position in 2011 and has since divided her time between hospital medicine and palliative care shifts in the hospital, although she now does palliative care exclusively.

Initially, she watched palliative care consults and asked for mentorship from the palliative care team. Although it took time to get used to the advisory role of the consultant, and to working with a team, she eventually became board certified in HPM.

“Palliative care is incredibly intense but richly rewarding work,” she says. “The patients you see are never simple. It allows us to practice the type of medicine we originally set out to do, with people at the most vulnerable times in their lives.”

Workforce, Fellowship, Board Certification

In October 2012, 3,356 physicians passed the hospice and palliative medicine subspecialty board exams offered by the American Board of Medical Specialties and 10 of its constituent specialty boards, with the lion’s share of them certified by the American Board of Internal Medicine. That more than doubled the number of physicians earning the HPM credential since its inception in 2008.

Even with the surge in palliative care training, workforce studies suggest the U.S. is woefully short of credentialed palliative care physicians. And many think hospitalists can help fill that void.

The Center to Advance Palliative Care (CAPC, www.capc.org) counts 1,400 hospital-based palliative care programs in the U.S., while the Centers for Medicare & Medicaid Services (CMS) recognizes about 3,500 Medicare-certified hospice programs. A 2010 estimate by Dale Lupu and the American Academy of Hospice and Palliative Medicine (AAHPM), however, suggested a need for between 4,487 and 10,810 palliative care physician FTEs just to staff existing programs at appropriate levels—without considering growth for the field or its spread into outpatient settings.¹

In the past, mid-career physicians had an experiential pathway to the HPM board exam, based on hours worked with a hospice or palliative care team, but physicians now must complete an HPM fellowship of at least one year in order to sit for the boards. And, according to AAHPM, only 234 HPM fellowship positions are offered nationwide by 85 approved fellowship programs.

Dr. Bekanich

A one-year fellowship is a big commitment for an established hospitalist, according to Stephen Bekanich, MD, co-director of Seton Palliative Care at Seton Healthcare, an 11-hospital system in Austin, Texas. A former hospitalist, Dr. Bekanich says that in his region a fellow stipend is about $70,000, whereas typical hospitalist compensation is in the mid- to upper-$200,000s.

AAHPM is exploring other approaches to expanding the workforce with mid-career physicians. One approach, authored by Timothy Quill, MD, and Amy Abernethy, MD, the past and current AAHPM board presidents, is to develop a two-tiered system in which palliative medicine specialists teach basic palliative care techniques and approaches to primary care physicians, hospitalists, and such specialists as oncologists.² The article also suggested equipping clinicians with the tools to recognize when more specialized help is needed.

“As in any medical discipline, some core elements of palliative care, such as aligning treatment with a patient’s goals and basic symptom management, should be routine aspects of care delivered by any practitioner,” Drs. Quill and Abernethy wrote. “Other skills are more complex and take years of training to learn and apply, such as negotiating a difficult family meeting, addressing veiled existential distress, and managing refractory symptoms.”

Dr. Bekanich is trying the two-tiered approach at Seton Healthcare. At facilities with no palliative care service, he is transplanting palliative-trained nurse practitioners in hospital medicine groups.

“This model is locked into our budget for fiscal year 2014,” Dr. Bekanich says. “We’ll train folks, starting with hospitalists and primary care physicians.”

The training will start with a pair of three-hour sessions on palliative care techniques for hospitalists and PCPs, followed by homework assignments. “Then we’ll meet again in three months to do some role plays,” he says.

Two final rounds of training will focus on skills, philosophy, values, and practice.

Palliative care is incredibly intense but richly rewarding work. The patients you see are never simple. It allows us to practice the type of medicine we originally set out to do, with people at the most vulnerable times in their lives.

—Marianne Novelli, MD, FHM, FACP, former chief of the division of hospital medicine, Kaiser Permanente, Denver, Colo.

On-the-Job Training

David Weissman, MD, FACP, a palliative care specialist in Milwaukee, Wis., and consultant to the CAPC, recommends hospitalists do what they can to improve their knowledge and skills. “There are a lot of opportunities for palliative care training out there,” he says.

HM conferences often include palliative care content. AAHPM and CAPC offer annual conferences that immerse participants in content, with opportunities to mingle with palliative care colleagues. AAHPM also offers specific content through its “Unipac” series of nine self-study training modules (www.aahpm.org/resources/default/unipac-4th-edition.html.)

Dr. Weissman

On the job, Dr. Weissman says hospitalists should ask for consults for patients with complex needs. Also pay attention to how the service works and what it recommends. Taking a couple of days to round with the palliative care service could be very educational. It may be possible to take a part-time position with the team, providing weekend or vacation coverage. Hospitalists can participate on planning or advisory committees for palliative care in their hospitals or on quality improvement projects.

“If there isn’t a palliative care service, advocate for developing one,” he says.

Local hospice programs, especially those with inpatient hospice facilities that need daily physician coverage, might have part-time staff positions, which could be a great moonlighting opportunity for hospitalists and a way to learn a lot very quickly.

“I can tell the difference between physicians who have spent time working in a hospice, where you can learn about caring for people at the end of life because most of the patients are so sick, and those who have not,” says Porter Storey, MD, FACP, AAHPM’s executive vice president and a practicing palliative care physician in Colorado. “You can learn how to use the medications to get someone comfortable quickly and how to talk to families in crisis. It can be some of the most rewarding work you can possibly do—especially when you have the time and training to do it well for some of the most challenging of patients and families.”

Dr. Storey recommends that hospitalists join AAHPM, use its professional materials, attend its annual meetings, and, if they feel a calling, consider fellowship training as the next big step.

“Palliative care programs are growing in number and size but are chronically understaffed,” says Steven Pantilat, MD, SFHM, hospitalist and director of the Palliative Care Program at the University of California at San Francisco. “This creates a great opportunity for hospitalists. I have heard of places that were having trouble recruiting palliative care physicians but were willing to sponsor a hospitalist to go and do a fellowship, supplementing their salary as an incentive—and a reasonable one—for a hospitalist interested in making a career move.”

He says that palliative care, like hospital medicine, has been a significant value-add in many hospitals and health systems. More importantly, it correlates to positive patient outcomes (see “Research Highlights Palliative Care Contributions,”).

Dr. Pantilat

“What’s new is how it connects to current issues like improved care transitions and readmissions reduction,” Dr. Pantilat says.

Advocates say palliative care helps to match medical services to patient preferences, thereby improving patient satisfaction scores, especially for those who aren’t likely to achieve good outcomes. Dr. Pantilat says it puts plans in place for patients to get the right services for the post-discharge period and for responding to anticipated problems like chest pain.

“It’s not just how to get patients out of the hospital as quickly as possible,” he says, “but to do that with a plan that sets them up to succeed at home.”

Larry Beresford is a freelance writer in San Francisco.

References

1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

The stories of patients and families, like this one presented by Kimberly Lastinger, offer powerful lessons for health professionals about the human experience of illness and its impact on the person and family. Furthermore, patient narratives present ‘experiential truth and passion’ that compel us to re-examine medical practices and ethical perceptions of care.¹ However much we think we know from our years of medical practice and our observation of many patients and families, we are not ‘in the patient’s shoes’. The content of patient narratives supports ethical decisions by helping us listen and hear what patients say, how they say it, and by clarifying why it matters. The patient story can help us focus healthcare on the patient and to recognize that the patient is the ultimate authority when it comes to the interpretation of his or her illness experience. Until one has been there, it is impossible to imagine the impact of a life-threatening illness. I am reminded of my own surprise at seeing, feeling, and experiencing the loss of a loved one to cancer. I have been a medical oncologist and palliative care physician for more than 25 years, and I thought I understood the experience I could expect when my husband died. Instead, I was stunned to find that I didn’t have a clue! It has taught me to listen more carefully and ask more questions. When listening occurs, understanding increases, and narratives can be jointly constructed by the patient and healthcare provider. This leads to power that is shared and the sharing of power constitutes an important ethical safeguard within the relationship.²

The narrative presented here suggests a remarkably positive experience of a devastating illness and its potential impact on the patient and family. The patient was someone with tremendous resiliency and optimism. She was commited to living on her terms and for caring for her daughter. Her story is an inspiring one. Ms Lastinger recalls her mother’s amazing support system, but also her mother’s fear of dying. The latter learned only years after her mother’s death from reading her journal. I wonder if, as too often happens, we failed to offer adequate psychosocial support. This service is too often not offered.^3,4 This occurs for many reasons including, I suspect, when there is the perception of a supportive social network embracing the patient. It behooves us as healthcare professionals to remember that patients may not want or be able to share some of their deepest fears, the threat of dying or of being dependent, with the people they love. The patients who seem to be doing well emotionally, those with ‘great support’ may also benefit from professional counseling.

The stories of patients and families, like this one presented by Kimberly Lastinger, offer powerful lessons for health professionals about the human experience of illness and its impact on the person and family. Furthermore, patient narratives present ‘experiential truth and passion’ that compel us to re-examine medical practices and ethical perceptions of care.¹ However much we think we know from our years of medical practice and our observation of many patients and families, we are not ‘in the patient’s shoes’. The content of patient narratives supports ethical decisions by helping us listen and hear what patients say, how they say it, and by clarifying why it matters. The patient story can help us focus healthcare on the patient and to recognize that the patient is the ultimate authority when it comes to the interpretation of his or her illness experience. Until one has been there, it is impossible to imagine the impact of a life-threatening illness. I am reminded of my own surprise at seeing, feeling, and experiencing the loss of a loved one to cancer. I have been a medical oncologist and palliative care physician for more than 25 years, and I thought I understood the experience I could expect when my husband died. Instead, I was stunned to find that I didn’t have a clue! It has taught me to listen more carefully and ask more questions. When listening occurs, understanding increases, and narratives can be jointly constructed by the patient and healthcare provider. This leads to power that is shared and the sharing of power constitutes an important ethical safeguard within the relationship.²

The narrative presented here suggests a remarkably positive experience of a devastating illness and its potential impact on the patient and family. The patient was someone with tremendous resiliency and optimism. She was commited to living on her terms and for caring for her daughter. Her story is an inspiring one. Ms Lastinger recalls her mother’s amazing support system, but also her mother’s fear of dying. The latter learned only years after her mother’s death from reading her journal. I wonder if, as too often happens, we failed to offer adequate psychosocial support. This service is too often not offered.^3,4 This occurs for many reasons including, I suspect, when there is the perception of a supportive social network embracing the patient. It behooves us as healthcare professionals to remember that patients may not want or be able to share some of their deepest fears, the threat of dying or of being dependent, with the people they love. The patients who seem to be doing well emotionally, those with ‘great support’ may also benefit from professional counseling.

The stories of patients and families, like this one presented by Kimberly Lastinger, offer powerful lessons for health professionals about the human experience of illness and its impact on the person and family. Furthermore, patient narratives present ‘experiential truth and passion’ that compel us to re-examine medical practices and ethical perceptions of care.¹ However much we think we know from our years of medical practice and our observation of many patients and families, we are not ‘in the patient’s shoes’. The content of patient narratives supports ethical decisions by helping us listen and hear what patients say, how they say it, and by clarifying why it matters. The patient story can help us focus healthcare on the patient and to recognize that the patient is the ultimate authority when it comes to the interpretation of his or her illness experience. Until one has been there, it is impossible to imagine the impact of a life-threatening illness. I am reminded of my own surprise at seeing, feeling, and experiencing the loss of a loved one to cancer. I have been a medical oncologist and palliative care physician for more than 25 years, and I thought I understood the experience I could expect when my husband died. Instead, I was stunned to find that I didn’t have a clue! It has taught me to listen more carefully and ask more questions. When listening occurs, understanding increases, and narratives can be jointly constructed by the patient and healthcare provider. This leads to power that is shared and the sharing of power constitutes an important ethical safeguard within the relationship.²

The narrative presented here suggests a remarkably positive experience of a devastating illness and its potential impact on the patient and family. The patient was someone with tremendous resiliency and optimism. She was commited to living on her terms and for caring for her daughter. Her story is an inspiring one. Ms Lastinger recalls her mother’s amazing support system, but also her mother’s fear of dying. The latter learned only years after her mother’s death from reading her journal. I wonder if, as too often happens, we failed to offer adequate psychosocial support. This service is too often not offered.^3,4 This occurs for many reasons including, I suspect, when there is the perception of a supportive social network embracing the patient. It behooves us as healthcare professionals to remember that patients may not want or be able to share some of their deepest fears, the threat of dying or of being dependent, with the people they love. The patients who seem to be doing well emotionally, those with ‘great support’ may also benefit from professional counseling.

Squamous cell carcinomas of the head and neck account for 3% of all new cancers diagnosed annually within the United States.¹ According to the Surveillance Epidemiology
and Ends Reports (SEER) database, 79% of patients in the US present with local or regional advanced disease and are treated with combinedmodality therapy.² Factors that influence treatment decision making include the following: resectability, function preservation, local patterns of care, and patient characteristics or preferences. In this cohort of patients, disease eradication is the goal of therapy. Conversely, for approximately 16% of patients who are diagnosed with metastatic disease at presentation, or the substantial portion of patients who develop non-curable disease recurrence, the main therapeutic objectives are palliation and prolongation of survival (accessible at http://seer.cancer.gov/statfacts/html/oralcav.html).^2,3 We define patients as having non-curable recurrence if development of metastatic disease or development of local recurrence is not amenable to either surgical resection or re-irradiation therapy. Several changes in the epidemiology and treatment of metastatic and recurrent head and neck cancer (M/RHNC) have resulted in paradigm shifts that effect treatment decision making in this population. First, a combination of standard chemotherapy with cetuximab has demonstrated a survival advantage. This is the first time that any agent or combination of agents has demonstrated superiority in the treatment of M/RHNC.⁴ Second, human papilloma virus (HPV)-associated oropharyngeal cancers are epidemic in many areas of the world. The cohort of HPV-positive patients has an excellent prognosis with currently available primary treatment regimens. The recurrence rate in this population is low; however, data regarding the treatment responsiveness of HPV-associated tumors that recur after primary therapy is lacking. Finally, with the increased use of aggressive combined modality regimens as primary therapy, patients with recurrent disease are often heavily pretreated and suffer from symptoms secondary to their initial therapy. It is important to understand how the evolving epidemiology and treatment paradigms affect decision making for our patients. This requires an understanding of how these changes affect both the benefits and risks to the patient.

Squamous cell carcinomas of the head and neck account for 3% of all new cancers diagnosed annually within the United States.¹ According to the Surveillance Epidemiology
and Ends Reports (SEER) database, 79% of patients in the US present with local or regional advanced disease and are treated with combinedmodality therapy.² Factors that influence treatment decision making include the following: resectability, function preservation, local patterns of care, and patient characteristics or preferences. In this cohort of patients, disease eradication is the goal of therapy. Conversely, for approximately 16% of patients who are diagnosed with metastatic disease at presentation, or the substantial portion of patients who develop non-curable disease recurrence, the main therapeutic objectives are palliation and prolongation of survival (accessible at http://seer.cancer.gov/statfacts/html/oralcav.html).^2,3 We define patients as having non-curable recurrence if development of metastatic disease or development of local recurrence is not amenable to either surgical resection or re-irradiation therapy. Several changes in the epidemiology and treatment of metastatic and recurrent head and neck cancer (M/RHNC) have resulted in paradigm shifts that effect treatment decision making in this population. First, a combination of standard chemotherapy with cetuximab has demonstrated a survival advantage. This is the first time that any agent or combination of agents has demonstrated superiority in the treatment of M/RHNC.⁴ Second, human papilloma virus (HPV)-associated oropharyngeal cancers are epidemic in many areas of the world. The cohort of HPV-positive patients has an excellent prognosis with currently available primary treatment regimens. The recurrence rate in this population is low; however, data regarding the treatment responsiveness of HPV-associated tumors that recur after primary therapy is lacking. Finally, with the increased use of aggressive combined modality regimens as primary therapy, patients with recurrent disease are often heavily pretreated and suffer from symptoms secondary to their initial therapy. It is important to understand how the evolving epidemiology and treatment paradigms affect decision making for our patients. This requires an understanding of how these changes affect both the benefits and risks to the patient.

Squamous cell carcinomas of the head and neck account for 3% of all new cancers diagnosed annually within the United States.¹ According to the Surveillance Epidemiology
and Ends Reports (SEER) database, 79% of patients in the US present with local or regional advanced disease and are treated with combinedmodality therapy.² Factors that influence treatment decision making include the following: resectability, function preservation, local patterns of care, and patient characteristics or preferences. In this cohort of patients, disease eradication is the goal of therapy. Conversely, for approximately 16% of patients who are diagnosed with metastatic disease at presentation, or the substantial portion of patients who develop non-curable disease recurrence, the main therapeutic objectives are palliation and prolongation of survival (accessible at http://seer.cancer.gov/statfacts/html/oralcav.html).^2,3 We define patients as having non-curable recurrence if development of metastatic disease or development of local recurrence is not amenable to either surgical resection or re-irradiation therapy. Several changes in the epidemiology and treatment of metastatic and recurrent head and neck cancer (M/RHNC) have resulted in paradigm shifts that effect treatment decision making in this population. First, a combination of standard chemotherapy with cetuximab has demonstrated a survival advantage. This is the first time that any agent or combination of agents has demonstrated superiority in the treatment of M/RHNC.⁴ Second, human papilloma virus (HPV)-associated oropharyngeal cancers are epidemic in many areas of the world. The cohort of HPV-positive patients has an excellent prognosis with currently available primary treatment regimens. The recurrence rate in this population is low; however, data regarding the treatment responsiveness of HPV-associated tumors that recur after primary therapy is lacking. Finally, with the increased use of aggressive combined modality regimens as primary therapy, patients with recurrent disease are often heavily pretreated and suffer from symptoms secondary to their initial therapy. It is important to understand how the evolving epidemiology and treatment paradigms affect decision making for our patients. This requires an understanding of how these changes affect both the benefits and risks to the patient.

I often daydream that my mom is still here and living cancer free. I like to imagine her teaching art at a prestigious private school in New York City, or maybe retired quilting in a little cottage in Vermont, or at home sketching on her back porch watching her dog playing in the yard. My mother battled cancer for over 20 years; and I find myself wondering what would it have been like to grow up without living under the shadow of the “c” word. How would things have been different? Would my mom still have been the fierce, strong, and passionate woman I remember? She never allowed herself to be a cancer patient. She was a mother, an artist, a friend, a teacher, and a cancer warrior. My mother was diagnosed with Stage II breast cancer in July of 1991. I was 7 years old and my younger sister was 2. She found a pea-sized lump in her left breast by self examination. Her treatment was to be a lumpectomy and radiation. While in surgery, they found numerous lumps in her left breast as well as her right breast and lymph nodes. My father had to make the decision for a radical mastectomy of her left breast and a partial of her right. It was very hard to see her going through all of it. I can remember having to spend a lot of time overnight with friends and family. There was a lot of crying and adults whispering. My mom was in bed most of the time and I remember waking up at night to her vomiting. At 7 years old, I knew words like mastectomy and chemotherapy. One night I couldn’t sleep and I went up stairs to ask my mom if she was dying. How do you answer that? My pediatrician told my mother to give me a journal so I could draw and write my thoughts and emotions. In the afternoons, the two of us would write in our journals. She kept my composition notebook filled with funny round people and lots of “x”s over my mommy’s “bueb”.

I often daydream that my mom is still here and living cancer free. I like to imagine her teaching art at a prestigious private school in New York City, or maybe retired quilting in a little cottage in Vermont, or at home sketching on her back porch watching her dog playing in the yard. My mother battled cancer for over 20 years; and I find myself wondering what would it have been like to grow up without living under the shadow of the “c” word. How would things have been different? Would my mom still have been the fierce, strong, and passionate woman I remember? She never allowed herself to be a cancer patient. She was a mother, an artist, a friend, a teacher, and a cancer warrior. My mother was diagnosed with Stage II breast cancer in July of 1991. I was 7 years old and my younger sister was 2. She found a pea-sized lump in her left breast by self examination. Her treatment was to be a lumpectomy and radiation. While in surgery, they found numerous lumps in her left breast as well as her right breast and lymph nodes. My father had to make the decision for a radical mastectomy of her left breast and a partial of her right. It was very hard to see her going through all of it. I can remember having to spend a lot of time overnight with friends and family. There was a lot of crying and adults whispering. My mom was in bed most of the time and I remember waking up at night to her vomiting. At 7 years old, I knew words like mastectomy and chemotherapy. One night I couldn’t sleep and I went up stairs to ask my mom if she was dying. How do you answer that? My pediatrician told my mother to give me a journal so I could draw and write my thoughts and emotions. In the afternoons, the two of us would write in our journals. She kept my composition notebook filled with funny round people and lots of “x”s over my mommy’s “bueb”.

I often daydream that my mom is still here and living cancer free. I like to imagine her teaching art at a prestigious private school in New York City, or maybe retired quilting in a little cottage in Vermont, or at home sketching on her back porch watching her dog playing in the yard. My mother battled cancer for over 20 years; and I find myself wondering what would it have been like to grow up without living under the shadow of the “c” word. How would things have been different? Would my mom still have been the fierce, strong, and passionate woman I remember? She never allowed herself to be a cancer patient. She was a mother, an artist, a friend, a teacher, and a cancer warrior. My mother was diagnosed with Stage II breast cancer in July of 1991. I was 7 years old and my younger sister was 2. She found a pea-sized lump in her left breast by self examination. Her treatment was to be a lumpectomy and radiation. While in surgery, they found numerous lumps in her left breast as well as her right breast and lymph nodes. My father had to make the decision for a radical mastectomy of her left breast and a partial of her right. It was very hard to see her going through all of it. I can remember having to spend a lot of time overnight with friends and family. There was a lot of crying and adults whispering. My mom was in bed most of the time and I remember waking up at night to her vomiting. At 7 years old, I knew words like mastectomy and chemotherapy. One night I couldn’t sleep and I went up stairs to ask my mom if she was dying. How do you answer that? My pediatrician told my mother to give me a journal so I could draw and write my thoughts and emotions. In the afternoons, the two of us would write in our journals. She kept my composition notebook filled with funny round people and lots of “x”s over my mommy’s “bueb”.