Earlier this summer, the Centers for Medicare & Medicaid Services (CMS) announced that more than 100,000 healthcare providers and 48% of all eligible hospitals are using electronic health records (EHRs) that meet federal standards, and they have benefited from federal incentive programs to do so.¹

According to CMS acting administrator Marilyn Tavenner, meeting that provider goal makes 2012 the “Year of Meaningful Use.” She also says healthcare providers have recognized the potential of EHRs to cut down on paperwork, eliminate duplicate screenings and tests, and facilitate better, safer, patient-centered care.²

Belying CMS’ celebratory declarations, however, are concerns among experts that health information technology’s (HIT) actual use falls short of its promise—and might even endanger patients—due to shortcomings in system interoperability, safety, accountability, and other issues.

“Federal funding of IT was a step in the right direction, but it has also created a guaranteed customer base for electronic medical records, so vendors have less incentive to improve their products to meet clinicians needs,” says Kendall M. Rogers, MD, CPE, FACP, SFHM, chair of SHsM’s IT Executive Committee and chief of hospital medicine at the University of New Mexico Health Sciences Center School of Medicine in Albuquerque. “We want systems that help us make better clinical decisions and allow us to work more efficiently. Unfortunately, many hospitalists are frustrated with existing HIT systems, knowing how much better they need to be. It can be a dangerous gamble to push rapid adoption of potentially unsafe systems in hospitals.”

Questioning HIT Safety

Health IT experts affirm that potential danger. Jerry Osheroff, MD, FACP, FACMI, principal and founder of TMIT Consulting LLC and former chief clinical informatics officer for Thomson Reuters Healthcare, says HIT “is most effective when it gets the right information to the right people, through the right channels, in the right format, at the right point in the workflow. The danger comes when it gets one of those five ‘rights’ wrong; that can lead to distraction, confusion, wasted time, missed improvement opportunities, and safety concerns.”

Last November, the Institute of Medicine (IOM) released a scathing critique of HIT’s current ability to ensure patient safety.3 As the federal government invests billions of dollars to encourage hospitals and healthcare providers to adopt HIT, the IOM report said, improvements in care and safety are not yet established, and little evidence exists that quantifies the magnitude of the risk associated with HIT problems—partly because many HIT vendors discourage providers from sharing patient-safety concerns with nondisclosure and “hold harmless” provisions in contracts that shift the liability of unsafe HIT features to care providers.³

The report also cautioned that serious errors involving these technologies—including medication dosing errors, failure to detect fatal illnesses, and treatment delays due to complex data interfaces and poor human-computer interactions or loss of data—have led to several reported patient deaths and injuries. Furthermore, there is no way to publicly track adverse outcomes because there is no systematic regulation or authority to collect, analyze, and disseminate such information.

The report concluded that the current state of safety and health IT is not acceptable and that regulation of the industry might be necessary because the private sector to date has not taken sufficient action on its own to improve HIT safety.

SHM applauds the IOM report as an overdue and direly needed call to action, Dr. Rogers says. SHM sent a letter to the U.S. Department of Health and Human Services underscoring the importance of the IOM report.

“In our practices, we have experienced the threats to patient safety outlined in the report: poor user-interface design, poor workflow, complex data interfaces, lack of system interoperability, and lack of sufficient vendor action to build safer products,” Dr. Rogers says.

“Lack of interoperability—preventing access to patient data from previous physician or other hospital visits—makes a mockery of a coordinated, patient-centered healthcare system,” says HIT researcher Ross Koppel, PhD, faculty member of University of Pennsylvania’s Sociology Department and School of Medicine.

Although Dr. Rogers acknowledges that HIT has the potential to revolutionize healthcare systems, boost quality and safety, and lower cost, he maintains that current HIT products fall short of those ambitious goals. “Vendors typically regard usability of their products as a convenience request by clinicians; any errors are regarded as training issues for physicians,” Dr. Rogers says. “But the way that data is presented on a screen matters—if it is difficult to input or retrieve data and leads to cognitive or process errors, that’s a product redesign issue for which vendors should be held accountable.”

Dr. Koppel says many HIT systems originated from billing system applications “and were not initially designed with the clinical perspective in mind. Hospitalists have to be particularly focused on usability of HIT systems when it comes to patient-safety impacts. They’re not the canary in the coal mine, they’re the miners—often the teachers guiding other clinicians on HIT use.”

Improvement Agenda

SHM fully supports many of the IOM’s recommendations to improve the safety and functionality of HIT systems, including these as stated in an email to its members:

• Remove contractual restrictions, promote public reporting of safety issues, and put a system in place for independent investigations that drive patient-safety improvement.
• Establish standards and a common infrastructure for “interoperable” data exchange across systems.
• Create dual accountability between vendors and providers to address safety concerns that might require
• changes in an IT product’s functionality or design.
• Promote research on usability and human-factors design, safer implementation, and sociotechnical systems associated with HIT.
• Promote education of safety, quality, and reliability principles in design and implementation of HIT among all levels of the workforce, including frontline clinicians and staff, hospital IT, and quality teams—as well as IT vendors themselves.

There also are ongoing efforts in the private sector to improve HIT system functionality. For example, the HIMSS CDS Guidebook Series, of which Dr. Osheroff is lead editor and author and Dr. Rogers is a contributing author, is a respected repository of information synthesizing and vetting critical guidance for the effective implementation of clinical decision support (CDS).

“We’re also working with Greg Maynard [senior vice president of SHM’s Center for Hospital Innovation & Improvement] to use the collaborative’s tools to disseminate clinical-decision-support best practices for improving VTE prophylaxis rates,” Dr. Osheroff notes.

Hospitalists, as central players in quality improvement (QI), standardization, and care coordination, are natural choices as HIT champions, with valuable insight into how HIT systems should be customized to accommodate workflows and order sets in an optimal fashion, Dr. Rogers says.

“As critical as we are about the status of current HIT systems, we believe that systems can be designed more effectively to meet our needs,” he says. “By adopting many of the improvements enumerated in the IOM report, hospitalists are uniquely positioned to advance HIT to help achieve the goals of safer, higher-quality, and more efficient care.”

Christopher Guadagnino is a freelance writer based in Philadelphia.

References

1. Centers for Medicare & Medicaid Services. More than 100,000 health care providers paid for using electronic health records. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4383&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&sr. Accessed July 31, 2012.
2. Centers for Medicare & Medicaid Services. 2012: the year of meaningful use. The CMS Blog website. Available at: http://blog.cms.gov/2012/03/23/2012-the-year-of-meaningful-use. Accessed July 18, 2012.
3. Institute of Medicine of the National Academies. Health IT and patient safety: building safer systems for better care. Institute of Medicine of the National Academies website. Available at: http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx. Accessed July 14, 2012.

Earlier this summer, the Centers for Medicare & Medicaid Services (CMS) announced that more than 100,000 healthcare providers and 48% of all eligible hospitals are using electronic health records (EHRs) that meet federal standards, and they have benefited from federal incentive programs to do so.¹

According to CMS acting administrator Marilyn Tavenner, meeting that provider goal makes 2012 the “Year of Meaningful Use.” She also says healthcare providers have recognized the potential of EHRs to cut down on paperwork, eliminate duplicate screenings and tests, and facilitate better, safer, patient-centered care.²

Belying CMS’ celebratory declarations, however, are concerns among experts that health information technology’s (HIT) actual use falls short of its promise—and might even endanger patients—due to shortcomings in system interoperability, safety, accountability, and other issues.

“Federal funding of IT was a step in the right direction, but it has also created a guaranteed customer base for electronic medical records, so vendors have less incentive to improve their products to meet clinicians needs,” says Kendall M. Rogers, MD, CPE, FACP, SFHM, chair of SHsM’s IT Executive Committee and chief of hospital medicine at the University of New Mexico Health Sciences Center School of Medicine in Albuquerque. “We want systems that help us make better clinical decisions and allow us to work more efficiently. Unfortunately, many hospitalists are frustrated with existing HIT systems, knowing how much better they need to be. It can be a dangerous gamble to push rapid adoption of potentially unsafe systems in hospitals.”

Questioning HIT Safety

Health IT experts affirm that potential danger. Jerry Osheroff, MD, FACP, FACMI, principal and founder of TMIT Consulting LLC and former chief clinical informatics officer for Thomson Reuters Healthcare, says HIT “is most effective when it gets the right information to the right people, through the right channels, in the right format, at the right point in the workflow. The danger comes when it gets one of those five ‘rights’ wrong; that can lead to distraction, confusion, wasted time, missed improvement opportunities, and safety concerns.”

Last November, the Institute of Medicine (IOM) released a scathing critique of HIT’s current ability to ensure patient safety.3 As the federal government invests billions of dollars to encourage hospitals and healthcare providers to adopt HIT, the IOM report said, improvements in care and safety are not yet established, and little evidence exists that quantifies the magnitude of the risk associated with HIT problems—partly because many HIT vendors discourage providers from sharing patient-safety concerns with nondisclosure and “hold harmless” provisions in contracts that shift the liability of unsafe HIT features to care providers.³

The report also cautioned that serious errors involving these technologies—including medication dosing errors, failure to detect fatal illnesses, and treatment delays due to complex data interfaces and poor human-computer interactions or loss of data—have led to several reported patient deaths and injuries. Furthermore, there is no way to publicly track adverse outcomes because there is no systematic regulation or authority to collect, analyze, and disseminate such information.

The report concluded that the current state of safety and health IT is not acceptable and that regulation of the industry might be necessary because the private sector to date has not taken sufficient action on its own to improve HIT safety.

SHM applauds the IOM report as an overdue and direly needed call to action, Dr. Rogers says. SHM sent a letter to the U.S. Department of Health and Human Services underscoring the importance of the IOM report.

“In our practices, we have experienced the threats to patient safety outlined in the report: poor user-interface design, poor workflow, complex data interfaces, lack of system interoperability, and lack of sufficient vendor action to build safer products,” Dr. Rogers says.

“Lack of interoperability—preventing access to patient data from previous physician or other hospital visits—makes a mockery of a coordinated, patient-centered healthcare system,” says HIT researcher Ross Koppel, PhD, faculty member of University of Pennsylvania’s Sociology Department and School of Medicine.

Although Dr. Rogers acknowledges that HIT has the potential to revolutionize healthcare systems, boost quality and safety, and lower cost, he maintains that current HIT products fall short of those ambitious goals. “Vendors typically regard usability of their products as a convenience request by clinicians; any errors are regarded as training issues for physicians,” Dr. Rogers says. “But the way that data is presented on a screen matters—if it is difficult to input or retrieve data and leads to cognitive or process errors, that’s a product redesign issue for which vendors should be held accountable.”

Dr. Koppel says many HIT systems originated from billing system applications “and were not initially designed with the clinical perspective in mind. Hospitalists have to be particularly focused on usability of HIT systems when it comes to patient-safety impacts. They’re not the canary in the coal mine, they’re the miners—often the teachers guiding other clinicians on HIT use.”

Improvement Agenda

SHM fully supports many of the IOM’s recommendations to improve the safety and functionality of HIT systems, including these as stated in an email to its members:

• Remove contractual restrictions, promote public reporting of safety issues, and put a system in place for independent investigations that drive patient-safety improvement.
• Establish standards and a common infrastructure for “interoperable” data exchange across systems.
• Create dual accountability between vendors and providers to address safety concerns that might require
• changes in an IT product’s functionality or design.
• Promote research on usability and human-factors design, safer implementation, and sociotechnical systems associated with HIT.
• Promote education of safety, quality, and reliability principles in design and implementation of HIT among all levels of the workforce, including frontline clinicians and staff, hospital IT, and quality teams—as well as IT vendors themselves.

There also are ongoing efforts in the private sector to improve HIT system functionality. For example, the HIMSS CDS Guidebook Series, of which Dr. Osheroff is lead editor and author and Dr. Rogers is a contributing author, is a respected repository of information synthesizing and vetting critical guidance for the effective implementation of clinical decision support (CDS).

“We’re also working with Greg Maynard [senior vice president of SHM’s Center for Hospital Innovation & Improvement] to use the collaborative’s tools to disseminate clinical-decision-support best practices for improving VTE prophylaxis rates,” Dr. Osheroff notes.

Hospitalists, as central players in quality improvement (QI), standardization, and care coordination, are natural choices as HIT champions, with valuable insight into how HIT systems should be customized to accommodate workflows and order sets in an optimal fashion, Dr. Rogers says.

“As critical as we are about the status of current HIT systems, we believe that systems can be designed more effectively to meet our needs,” he says. “By adopting many of the improvements enumerated in the IOM report, hospitalists are uniquely positioned to advance HIT to help achieve the goals of safer, higher-quality, and more efficient care.”

Christopher Guadagnino is a freelance writer based in Philadelphia.

References

1. Centers for Medicare & Medicaid Services. More than 100,000 health care providers paid for using electronic health records. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4383&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&sr. Accessed July 31, 2012.
2. Centers for Medicare & Medicaid Services. 2012: the year of meaningful use. The CMS Blog website. Available at: http://blog.cms.gov/2012/03/23/2012-the-year-of-meaningful-use. Accessed July 18, 2012.
3. Institute of Medicine of the National Academies. Health IT and patient safety: building safer systems for better care. Institute of Medicine of the National Academies website. Available at: http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx. Accessed July 14, 2012.

Earlier this summer, the Centers for Medicare & Medicaid Services (CMS) announced that more than 100,000 healthcare providers and 48% of all eligible hospitals are using electronic health records (EHRs) that meet federal standards, and they have benefited from federal incentive programs to do so.¹

According to CMS acting administrator Marilyn Tavenner, meeting that provider goal makes 2012 the “Year of Meaningful Use.” She also says healthcare providers have recognized the potential of EHRs to cut down on paperwork, eliminate duplicate screenings and tests, and facilitate better, safer, patient-centered care.²

Belying CMS’ celebratory declarations, however, are concerns among experts that health information technology’s (HIT) actual use falls short of its promise—and might even endanger patients—due to shortcomings in system interoperability, safety, accountability, and other issues.

“Federal funding of IT was a step in the right direction, but it has also created a guaranteed customer base for electronic medical records, so vendors have less incentive to improve their products to meet clinicians needs,” says Kendall M. Rogers, MD, CPE, FACP, SFHM, chair of SHsM’s IT Executive Committee and chief of hospital medicine at the University of New Mexico Health Sciences Center School of Medicine in Albuquerque. “We want systems that help us make better clinical decisions and allow us to work more efficiently. Unfortunately, many hospitalists are frustrated with existing HIT systems, knowing how much better they need to be. It can be a dangerous gamble to push rapid adoption of potentially unsafe systems in hospitals.”

Questioning HIT Safety

Health IT experts affirm that potential danger. Jerry Osheroff, MD, FACP, FACMI, principal and founder of TMIT Consulting LLC and former chief clinical informatics officer for Thomson Reuters Healthcare, says HIT “is most effective when it gets the right information to the right people, through the right channels, in the right format, at the right point in the workflow. The danger comes when it gets one of those five ‘rights’ wrong; that can lead to distraction, confusion, wasted time, missed improvement opportunities, and safety concerns.”

Last November, the Institute of Medicine (IOM) released a scathing critique of HIT’s current ability to ensure patient safety.3 As the federal government invests billions of dollars to encourage hospitals and healthcare providers to adopt HIT, the IOM report said, improvements in care and safety are not yet established, and little evidence exists that quantifies the magnitude of the risk associated with HIT problems—partly because many HIT vendors discourage providers from sharing patient-safety concerns with nondisclosure and “hold harmless” provisions in contracts that shift the liability of unsafe HIT features to care providers.³

The report also cautioned that serious errors involving these technologies—including medication dosing errors, failure to detect fatal illnesses, and treatment delays due to complex data interfaces and poor human-computer interactions or loss of data—have led to several reported patient deaths and injuries. Furthermore, there is no way to publicly track adverse outcomes because there is no systematic regulation or authority to collect, analyze, and disseminate such information.

The report concluded that the current state of safety and health IT is not acceptable and that regulation of the industry might be necessary because the private sector to date has not taken sufficient action on its own to improve HIT safety.

SHM applauds the IOM report as an overdue and direly needed call to action, Dr. Rogers says. SHM sent a letter to the U.S. Department of Health and Human Services underscoring the importance of the IOM report.

“In our practices, we have experienced the threats to patient safety outlined in the report: poor user-interface design, poor workflow, complex data interfaces, lack of system interoperability, and lack of sufficient vendor action to build safer products,” Dr. Rogers says.

“Lack of interoperability—preventing access to patient data from previous physician or other hospital visits—makes a mockery of a coordinated, patient-centered healthcare system,” says HIT researcher Ross Koppel, PhD, faculty member of University of Pennsylvania’s Sociology Department and School of Medicine.

Although Dr. Rogers acknowledges that HIT has the potential to revolutionize healthcare systems, boost quality and safety, and lower cost, he maintains that current HIT products fall short of those ambitious goals. “Vendors typically regard usability of their products as a convenience request by clinicians; any errors are regarded as training issues for physicians,” Dr. Rogers says. “But the way that data is presented on a screen matters—if it is difficult to input or retrieve data and leads to cognitive or process errors, that’s a product redesign issue for which vendors should be held accountable.”

Dr. Koppel says many HIT systems originated from billing system applications “and were not initially designed with the clinical perspective in mind. Hospitalists have to be particularly focused on usability of HIT systems when it comes to patient-safety impacts. They’re not the canary in the coal mine, they’re the miners—often the teachers guiding other clinicians on HIT use.”

Improvement Agenda

SHM fully supports many of the IOM’s recommendations to improve the safety and functionality of HIT systems, including these as stated in an email to its members:

• Remove contractual restrictions, promote public reporting of safety issues, and put a system in place for independent investigations that drive patient-safety improvement.
• Establish standards and a common infrastructure for “interoperable” data exchange across systems.
• Create dual accountability between vendors and providers to address safety concerns that might require
• changes in an IT product’s functionality or design.
• Promote research on usability and human-factors design, safer implementation, and sociotechnical systems associated with HIT.
• Promote education of safety, quality, and reliability principles in design and implementation of HIT among all levels of the workforce, including frontline clinicians and staff, hospital IT, and quality teams—as well as IT vendors themselves.

There also are ongoing efforts in the private sector to improve HIT system functionality. For example, the HIMSS CDS Guidebook Series, of which Dr. Osheroff is lead editor and author and Dr. Rogers is a contributing author, is a respected repository of information synthesizing and vetting critical guidance for the effective implementation of clinical decision support (CDS).

“We’re also working with Greg Maynard [senior vice president of SHM’s Center for Hospital Innovation & Improvement] to use the collaborative’s tools to disseminate clinical-decision-support best practices for improving VTE prophylaxis rates,” Dr. Osheroff notes.

Hospitalists, as central players in quality improvement (QI), standardization, and care coordination, are natural choices as HIT champions, with valuable insight into how HIT systems should be customized to accommodate workflows and order sets in an optimal fashion, Dr. Rogers says.

“As critical as we are about the status of current HIT systems, we believe that systems can be designed more effectively to meet our needs,” he says. “By adopting many of the improvements enumerated in the IOM report, hospitalists are uniquely positioned to advance HIT to help achieve the goals of safer, higher-quality, and more efficient care.”

Christopher Guadagnino is a freelance writer based in Philadelphia.

References

1. Centers for Medicare & Medicaid Services. More than 100,000 health care providers paid for using electronic health records. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4383&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&sr. Accessed July 31, 2012.
2. Centers for Medicare & Medicaid Services. 2012: the year of meaningful use. The CMS Blog website. Available at: http://blog.cms.gov/2012/03/23/2012-the-year-of-meaningful-use. Accessed July 18, 2012.
3. Institute of Medicine of the National Academies. Health IT and patient safety: building safer systems for better care. Institute of Medicine of the National Academies website. Available at: http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx. Accessed July 14, 2012.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Chithra Perumalswami, MD, knew early on what she wanted to do with her life. As a teenager, she volunteered in an ED and with a hospice group, volunteerism that continued throughout her education. When she graduated from high school, she was tapped for Brown University’s Program in Liberal Medical Education, which calls itself the only baccalaureate-MD program in the Ivy League. And though she eventually turned down the offer, she pursued dual majors in cellular and molecular biology and English at the University of Michigan, where she earned her medical degree in 2004 and completed her residency.

In 2009, she participated in the Palliative Care Education and Practice Program at Harvard Medical School in Boston, a two-week post-graduate course aimed at professional development for physicians dedicated to careers in palliative-care education. “I really found that there were just so many aspects to caring for a patient as a palliative-care specialist and as a hospitalist that really strike at the heart of what being a doctor is,” says Dr. Perumalswami, assistant professor of medicine in the Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago and one of four new members of Team Hospitalist. “I think it’s been an interest I’ve always had. During my residency training, I definitely experienced quite a few patient cases where I felt that we really needed to help patients and their families, and I didn’t necessarily have the best skill set to do that until I had more experience and more training.”

Dr. Perumalswami now wants to get better at her craft.

“As an academic hospitalist, it’s not just about doing research and writing papers and seeing papers,” she says, “but it’s also developing those leadership skills and helping that become an integral part of the educational experience.”

Question: What drew you to a career in HM?

Answer: I chose a career in academic hospital medicine primarily because I enjoy taking care of acutely ill, hospitalized, adult patients. I also really enjoy teaching medical students, residents, and fellows, and I enjoy doing that in the hospital setting. I think that there’s great satisfaction from taking care of a patient from admission to discharge.… I enjoyed every aspect of internal medicine, and when I graduated, I thought I could choose a subspecialty, but I felt that my skills and my expertise was really in taking care of the hospitalized patient.

Q: You have sought out extra training in palliative care and pain management. How has that impacted your career?

A: It’s not something that I necessarily started out thinking that I would specialize in, but the more I took care of hospitalized patients, the more I realized that we actually take care of a fair number of patients who have really complex symptom needs, and also really have a lot of needs with regard to recognizing when their prognosis is poor and understanding what their options are, if they’re even amenable to a palliative approach. I really felt that that was a skill that I needed to fine-tune. So I ended up gaining enough clinical experience and participating with hospice patients to the point where that’s really supplemented my hospitalist career, because what I found is that it’s made me a better hospitalist, and being a hospitalist has made me a better palliative-care doc.

Q: Working in academia, there’s no way to escape talk of the duty-hour rules recently put in place. What’s your view on the issue?

A: My view is that the work hours are here to stay. I think that there are some definite benefits that we’ve gained from having work hours. I’d say first and foremost of those gains is public trust. I think most physicians will tell you that they don’t want a physician who’s in the 36th hour of their day taking care of them when we know that studies actually can demonstrate that when you’ve been awake that long, that your cognitive abilities decline.

Q: But?

A: I think we have a lot of challenges, though, because a lot of things require creative solutions. And I think the first on that list is education, because that’s the first thing that I think has the potential to drop to the bottom of the list.

Q: In terms of HM’s growth, as you see residents coming through your program, how popular do you think the model is going to be with them moving forward?

A: I do, actually, because as an academic hospitalist, I’ve had several medical students and residents tell me, “Watching you, I think that I want to go into this field.” Or they’ll say, “What do you think about doing this for a year or two?” Or, “What do you think about subspecializing, and then being a hospitalist?” And my answer to all of them is it’s a dynamic specialty, and if you’re up for creating change and being a leader, it’s a good field, because we need people in a lot of different buckets, so to speak. We need people who have done other things in their career to contribute to our field.

Q: How do you prepare trainees for all the challenges coming down the pike?

A: A lot of the people who are doing work in medical education are starting to look to other fields to see if there are other models that we can adapt, or that we can somehow absorb into our practice. I think that there are some parts of our education which are not really formalized early on, but I think we have a lot to learn from organizational behavior circles, and systems that actually look at teams and leadership.

Q: What do the next five to 10 years hold for you?

A: All physician leaders have to stay somewhat in the clinical world. I think if you lose sight of that, you can’t be a very effective leader, or a very effective agent for change. Because part of my work is with palliative care, and I really feel that it’s affected my work as a hospitalist in a positive way, I don’t think I ever see myself leaving the clinical world completely. But I do see myself becoming, ideally, more involved with leadership and more involved with helping to train the next set of leaders.

Q: What do you see as SHM’s role specific to academic HM?

A: HM is changing the way healthcare is delivered in the U.S., and I think having an organization to represent us is vital to our success in other arenas of change—including healthcare policy and innovative care models. I see SHM as a large umbrella group, of which academic HM is one part. Academic hospitalists are increasingly involved in the education of future generations of physicians, and are uniquely poised for facilitating cascading leadership. The traditional, hierarchical model of attending-fellow-resident-medical student is shifting, and academic hospitalists are well-suited to study and explore this leadership structure and how it affects patient care, feedback, and mentoring.

Richard Quinn is a freelance writer based in New Jersey.

Chithra Perumalswami, MD, knew early on what she wanted to do with her life. As a teenager, she volunteered in an ED and with a hospice group, volunteerism that continued throughout her education. When she graduated from high school, she was tapped for Brown University’s Program in Liberal Medical Education, which calls itself the only baccalaureate-MD program in the Ivy League. And though she eventually turned down the offer, she pursued dual majors in cellular and molecular biology and English at the University of Michigan, where she earned her medical degree in 2004 and completed her residency.

In 2009, she participated in the Palliative Care Education and Practice Program at Harvard Medical School in Boston, a two-week post-graduate course aimed at professional development for physicians dedicated to careers in palliative-care education. “I really found that there were just so many aspects to caring for a patient as a palliative-care specialist and as a hospitalist that really strike at the heart of what being a doctor is,” says Dr. Perumalswami, assistant professor of medicine in the Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago and one of four new members of Team Hospitalist. “I think it’s been an interest I’ve always had. During my residency training, I definitely experienced quite a few patient cases where I felt that we really needed to help patients and their families, and I didn’t necessarily have the best skill set to do that until I had more experience and more training.”

Dr. Perumalswami now wants to get better at her craft.

“As an academic hospitalist, it’s not just about doing research and writing papers and seeing papers,” she says, “but it’s also developing those leadership skills and helping that become an integral part of the educational experience.”

Question: What drew you to a career in HM?

Answer: I chose a career in academic hospital medicine primarily because I enjoy taking care of acutely ill, hospitalized, adult patients. I also really enjoy teaching medical students, residents, and fellows, and I enjoy doing that in the hospital setting. I think that there’s great satisfaction from taking care of a patient from admission to discharge.… I enjoyed every aspect of internal medicine, and when I graduated, I thought I could choose a subspecialty, but I felt that my skills and my expertise was really in taking care of the hospitalized patient.

Q: You have sought out extra training in palliative care and pain management. How has that impacted your career?

A: It’s not something that I necessarily started out thinking that I would specialize in, but the more I took care of hospitalized patients, the more I realized that we actually take care of a fair number of patients who have really complex symptom needs, and also really have a lot of needs with regard to recognizing when their prognosis is poor and understanding what their options are, if they’re even amenable to a palliative approach. I really felt that that was a skill that I needed to fine-tune. So I ended up gaining enough clinical experience and participating with hospice patients to the point where that’s really supplemented my hospitalist career, because what I found is that it’s made me a better hospitalist, and being a hospitalist has made me a better palliative-care doc.

Q: Working in academia, there’s no way to escape talk of the duty-hour rules recently put in place. What’s your view on the issue?

A: My view is that the work hours are here to stay. I think that there are some definite benefits that we’ve gained from having work hours. I’d say first and foremost of those gains is public trust. I think most physicians will tell you that they don’t want a physician who’s in the 36th hour of their day taking care of them when we know that studies actually can demonstrate that when you’ve been awake that long, that your cognitive abilities decline.

Q: But?

A: I think we have a lot of challenges, though, because a lot of things require creative solutions. And I think the first on that list is education, because that’s the first thing that I think has the potential to drop to the bottom of the list.

Q: In terms of HM’s growth, as you see residents coming through your program, how popular do you think the model is going to be with them moving forward?

A: I do, actually, because as an academic hospitalist, I’ve had several medical students and residents tell me, “Watching you, I think that I want to go into this field.” Or they’ll say, “What do you think about doing this for a year or two?” Or, “What do you think about subspecializing, and then being a hospitalist?” And my answer to all of them is it’s a dynamic specialty, and if you’re up for creating change and being a leader, it’s a good field, because we need people in a lot of different buckets, so to speak. We need people who have done other things in their career to contribute to our field.

Q: How do you prepare trainees for all the challenges coming down the pike?

A: A lot of the people who are doing work in medical education are starting to look to other fields to see if there are other models that we can adapt, or that we can somehow absorb into our practice. I think that there are some parts of our education which are not really formalized early on, but I think we have a lot to learn from organizational behavior circles, and systems that actually look at teams and leadership.

Q: What do the next five to 10 years hold for you?

A: All physician leaders have to stay somewhat in the clinical world. I think if you lose sight of that, you can’t be a very effective leader, or a very effective agent for change. Because part of my work is with palliative care, and I really feel that it’s affected my work as a hospitalist in a positive way, I don’t think I ever see myself leaving the clinical world completely. But I do see myself becoming, ideally, more involved with leadership and more involved with helping to train the next set of leaders.

Q: What do you see as SHM’s role specific to academic HM?

A: HM is changing the way healthcare is delivered in the U.S., and I think having an organization to represent us is vital to our success in other arenas of change—including healthcare policy and innovative care models. I see SHM as a large umbrella group, of which academic HM is one part. Academic hospitalists are increasingly involved in the education of future generations of physicians, and are uniquely poised for facilitating cascading leadership. The traditional, hierarchical model of attending-fellow-resident-medical student is shifting, and academic hospitalists are well-suited to study and explore this leadership structure and how it affects patient care, feedback, and mentoring.

Richard Quinn is a freelance writer based in New Jersey.

Chithra Perumalswami, MD, knew early on what she wanted to do with her life. As a teenager, she volunteered in an ED and with a hospice group, volunteerism that continued throughout her education. When she graduated from high school, she was tapped for Brown University’s Program in Liberal Medical Education, which calls itself the only baccalaureate-MD program in the Ivy League. And though she eventually turned down the offer, she pursued dual majors in cellular and molecular biology and English at the University of Michigan, where she earned her medical degree in 2004 and completed her residency.

In 2009, she participated in the Palliative Care Education and Practice Program at Harvard Medical School in Boston, a two-week post-graduate course aimed at professional development for physicians dedicated to careers in palliative-care education. “I really found that there were just so many aspects to caring for a patient as a palliative-care specialist and as a hospitalist that really strike at the heart of what being a doctor is,” says Dr. Perumalswami, assistant professor of medicine in the Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago and one of four new members of Team Hospitalist. “I think it’s been an interest I’ve always had. During my residency training, I definitely experienced quite a few patient cases where I felt that we really needed to help patients and their families, and I didn’t necessarily have the best skill set to do that until I had more experience and more training.”

Dr. Perumalswami now wants to get better at her craft.

“As an academic hospitalist, it’s not just about doing research and writing papers and seeing papers,” she says, “but it’s also developing those leadership skills and helping that become an integral part of the educational experience.”

Question: What drew you to a career in HM?

Answer: I chose a career in academic hospital medicine primarily because I enjoy taking care of acutely ill, hospitalized, adult patients. I also really enjoy teaching medical students, residents, and fellows, and I enjoy doing that in the hospital setting. I think that there’s great satisfaction from taking care of a patient from admission to discharge.… I enjoyed every aspect of internal medicine, and when I graduated, I thought I could choose a subspecialty, but I felt that my skills and my expertise was really in taking care of the hospitalized patient.

Q: You have sought out extra training in palliative care and pain management. How has that impacted your career?

A: It’s not something that I necessarily started out thinking that I would specialize in, but the more I took care of hospitalized patients, the more I realized that we actually take care of a fair number of patients who have really complex symptom needs, and also really have a lot of needs with regard to recognizing when their prognosis is poor and understanding what their options are, if they’re even amenable to a palliative approach. I really felt that that was a skill that I needed to fine-tune. So I ended up gaining enough clinical experience and participating with hospice patients to the point where that’s really supplemented my hospitalist career, because what I found is that it’s made me a better hospitalist, and being a hospitalist has made me a better palliative-care doc.

Q: Working in academia, there’s no way to escape talk of the duty-hour rules recently put in place. What’s your view on the issue?

A: My view is that the work hours are here to stay. I think that there are some definite benefits that we’ve gained from having work hours. I’d say first and foremost of those gains is public trust. I think most physicians will tell you that they don’t want a physician who’s in the 36th hour of their day taking care of them when we know that studies actually can demonstrate that when you’ve been awake that long, that your cognitive abilities decline.

Q: But?

A: I think we have a lot of challenges, though, because a lot of things require creative solutions. And I think the first on that list is education, because that’s the first thing that I think has the potential to drop to the bottom of the list.

Q: In terms of HM’s growth, as you see residents coming through your program, how popular do you think the model is going to be with them moving forward?

A: I do, actually, because as an academic hospitalist, I’ve had several medical students and residents tell me, “Watching you, I think that I want to go into this field.” Or they’ll say, “What do you think about doing this for a year or two?” Or, “What do you think about subspecializing, and then being a hospitalist?” And my answer to all of them is it’s a dynamic specialty, and if you’re up for creating change and being a leader, it’s a good field, because we need people in a lot of different buckets, so to speak. We need people who have done other things in their career to contribute to our field.

Q: How do you prepare trainees for all the challenges coming down the pike?

A: A lot of the people who are doing work in medical education are starting to look to other fields to see if there are other models that we can adapt, or that we can somehow absorb into our practice. I think that there are some parts of our education which are not really formalized early on, but I think we have a lot to learn from organizational behavior circles, and systems that actually look at teams and leadership.

Q: What do the next five to 10 years hold for you?

A: All physician leaders have to stay somewhat in the clinical world. I think if you lose sight of that, you can’t be a very effective leader, or a very effective agent for change. Because part of my work is with palliative care, and I really feel that it’s affected my work as a hospitalist in a positive way, I don’t think I ever see myself leaving the clinical world completely. But I do see myself becoming, ideally, more involved with leadership and more involved with helping to train the next set of leaders.

Q: What do you see as SHM’s role specific to academic HM?

A: HM is changing the way healthcare is delivered in the U.S., and I think having an organization to represent us is vital to our success in other arenas of change—including healthcare policy and innovative care models. I see SHM as a large umbrella group, of which academic HM is one part. Academic hospitalists are increasingly involved in the education of future generations of physicians, and are uniquely poised for facilitating cascading leadership. The traditional, hierarchical model of attending-fellow-resident-medical student is shifting, and academic hospitalists are well-suited to study and explore this leadership structure and how it affects patient care, feedback, and mentoring.

Richard Quinn is a freelance writer based in New Jersey.

The OB/GYN hospitalist field is growing, with at least 164 identified programs and 1,500 to 2,500 practitioners who spend all or part of their workweek in hospital labor and delivery departments. SHM and the American College of Obstetricians and Gynecologists helped birth the 90-member Society of OB/GYN Hospitalists in 2011, but it is now independent, says founding president Rob Olson, MD, an OB/GYN hospitalist practicing in Bellingham, Wash. The fledgling society is planning its second annual conference, Sept. 27-29 in Denver, with obstetric emergency simulation training, clinical lectures, and pearls from the experience of general hospitalist practice by HM pioneer John Nelson, MD, MHM.

Also known as laborists, these board-certified OB/GYN docs’ dedicated presence affords rapid on-site response to changes in patients’ conditions, Dr. Olson says. Laborists might cover nights and weekends, pick up unassigned patients, or cover for private obstetricians who are fully engaged. Laborists do not supplant the private practitioner’s role in delivering babies in the hospital, Dr. Olson says, “unless the private physician asks them to,” which, he adds, is happening more often.

Laborists typically are limited to labor and delivery services, although some also address gynecological cases in the ED. Most of the programs provide coverage 24/7, and invariably they are in facilities with medical hospitalists who might consult on medical complications for expectant mothers. One to two new programs open every month, Dr. Olson says, and his website lists 120 job openings. For information, visit www.ObGynHospitalist.com.

The OB/GYN hospitalist field is growing, with at least 164 identified programs and 1,500 to 2,500 practitioners who spend all or part of their workweek in hospital labor and delivery departments. SHM and the American College of Obstetricians and Gynecologists helped birth the 90-member Society of OB/GYN Hospitalists in 2011, but it is now independent, says founding president Rob Olson, MD, an OB/GYN hospitalist practicing in Bellingham, Wash. The fledgling society is planning its second annual conference, Sept. 27-29 in Denver, with obstetric emergency simulation training, clinical lectures, and pearls from the experience of general hospitalist practice by HM pioneer John Nelson, MD, MHM.

Also known as laborists, these board-certified OB/GYN docs’ dedicated presence affords rapid on-site response to changes in patients’ conditions, Dr. Olson says. Laborists might cover nights and weekends, pick up unassigned patients, or cover for private obstetricians who are fully engaged. Laborists do not supplant the private practitioner’s role in delivering babies in the hospital, Dr. Olson says, “unless the private physician asks them to,” which, he adds, is happening more often.

Laborists typically are limited to labor and delivery services, although some also address gynecological cases in the ED. Most of the programs provide coverage 24/7, and invariably they are in facilities with medical hospitalists who might consult on medical complications for expectant mothers. One to two new programs open every month, Dr. Olson says, and his website lists 120 job openings. For information, visit www.ObGynHospitalist.com.

The OB/GYN hospitalist field is growing, with at least 164 identified programs and 1,500 to 2,500 practitioners who spend all or part of their workweek in hospital labor and delivery departments. SHM and the American College of Obstetricians and Gynecologists helped birth the 90-member Society of OB/GYN Hospitalists in 2011, but it is now independent, says founding president Rob Olson, MD, an OB/GYN hospitalist practicing in Bellingham, Wash. The fledgling society is planning its second annual conference, Sept. 27-29 in Denver, with obstetric emergency simulation training, clinical lectures, and pearls from the experience of general hospitalist practice by HM pioneer John Nelson, MD, MHM.

Also known as laborists, these board-certified OB/GYN docs’ dedicated presence affords rapid on-site response to changes in patients’ conditions, Dr. Olson says. Laborists might cover nights and weekends, pick up unassigned patients, or cover for private obstetricians who are fully engaged. Laborists do not supplant the private practitioner’s role in delivering babies in the hospital, Dr. Olson says, “unless the private physician asks them to,” which, he adds, is happening more often.

Laborists typically are limited to labor and delivery services, although some also address gynecological cases in the ED. Most of the programs provide coverage 24/7, and invariably they are in facilities with medical hospitalists who might consult on medical complications for expectant mothers. One to two new programs open every month, Dr. Olson says, and his website lists 120 job openings. For information, visit www.ObGynHospitalist.com.

A new hospital patient-safety ranking system was released in July by Consumers Union (CU), an independent consumer advocacy organization in Yonkers, N.Y., and published in the August issue of its magazine Consumer Reports.¹ CU rated 1,155 hospitals in six categories, including hospital-acquired infections, readmissions, and the quality of communication by physicians and nurses to patients. The highest-scoring hospital: Billings Clinic in Montana, which received a 72 on CU’s 100-point safety score.

“The new Consumer Reports hospital safety ratings add to a growing list of publicly reported performance rating schemes,” says SHM president Shaun Frost, MD, SFHM, FACP, associate medical director for care-delivery systems at HealthPartners in Minneapolis. Hospitalists should be aware of these ratings and review them “with an eye toward identifying improvement opportunities that are within their scope of influence....Hospitalists must embrace these issues as theirs to own and improve upon, as the ability to demonstrably improve the safety and care quality in the hospitals in which we practice is dependent on us.”

Reference

1. Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed July 31, 2012.

A new hospital patient-safety ranking system was released in July by Consumers Union (CU), an independent consumer advocacy organization in Yonkers, N.Y., and published in the August issue of its magazine Consumer Reports.¹ CU rated 1,155 hospitals in six categories, including hospital-acquired infections, readmissions, and the quality of communication by physicians and nurses to patients. The highest-scoring hospital: Billings Clinic in Montana, which received a 72 on CU’s 100-point safety score.

“The new Consumer Reports hospital safety ratings add to a growing list of publicly reported performance rating schemes,” says SHM president Shaun Frost, MD, SFHM, FACP, associate medical director for care-delivery systems at HealthPartners in Minneapolis. Hospitalists should be aware of these ratings and review them “with an eye toward identifying improvement opportunities that are within their scope of influence....Hospitalists must embrace these issues as theirs to own and improve upon, as the ability to demonstrably improve the safety and care quality in the hospitals in which we practice is dependent on us.”

Reference

1. Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed July 31, 2012.

A new hospital patient-safety ranking system was released in July by Consumers Union (CU), an independent consumer advocacy organization in Yonkers, N.Y., and published in the August issue of its magazine Consumer Reports.¹ CU rated 1,155 hospitals in six categories, including hospital-acquired infections, readmissions, and the quality of communication by physicians and nurses to patients. The highest-scoring hospital: Billings Clinic in Montana, which received a 72 on CU’s 100-point safety score.

“The new Consumer Reports hospital safety ratings add to a growing list of publicly reported performance rating schemes,” says SHM president Shaun Frost, MD, SFHM, FACP, associate medical director for care-delivery systems at HealthPartners in Minneapolis. Hospitalists should be aware of these ratings and review them “with an eye toward identifying improvement opportunities that are within their scope of influence....Hospitalists must embrace these issues as theirs to own and improve upon, as the ability to demonstrably improve the safety and care quality in the hospitals in which we practice is dependent on us.”

Reference

1. Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed July 31, 2012.

Prairie Business Magazine recently reported that hospitalist Neville Alberto, MD, FACP, of Sanford Health in Fargo, N.D., carries on his rounds not a stethoscope but “a portable ultrasound draped around his neck.”¹ The article illustrates ultrasound’s increased portability, wider application at the hospital bedside, and increased use by trained hospitalists. It’s a topic also discussed in a recent post by Robert Wachter, MD, MHM, author of the blog Wachter’s World, professor, and chief of the division of hospital medicine at the University of California at San Francisco (UCSF). Dr. Wachter says “the time has come to—carefully and thoughtfully—add hospitalists” to the growing list of medical specialties that have staked a claim to a procedure previously reserved for radiologists.²

“The one I carry on me is no larger than my smartphone,” Dr. Alberto explains. “It’s well-placed, so nobody notices.”

A hospitalist since 2001, Dr. Alberto is often on the move in his seven-story hospital building. He uses the device to assist in determining whether a patient needs more fluids, or to examine an elderly patient’s bladder for urinary retention when a urinary tract infection is suspected. Only a few colleagues in Dr. Alberto’s 22-member hospitalist group are as comfortable with ultrasound technology, he says, but he has helped develop a curriculum to teach ultrasound techniques to physicians, residents, and medical students.

Diane Sliwka, MD, a UCSF hospitalist and advocate for more widespread ultrasound use by hospitalists, says most physicians have yet to adopt the technology as fully as Dr. Alberto has. “But they’ve seen it and they want it,” she adds.

Hospitalists first utilized portable ultrasound to guide such procedures as thoracentesis or paracentesis. Increasingly, it is being used to assess, for example, cardiac function, fluid buildup around the heart, or the location of a blood clot—“when decisions are needed quickly about what’s going on and how to treat it,” she says. Other growing targets include lung pathologies (pneumothorax) and differentiating between COPD and pulmonary edema, or pneumonia and gallstones, she says.

The technology is advancing faster than the speed of light, with an iPad/tablet application in the works, according to a recent Technology Review blog post from the Massachusetts Institute of Technology.³

References

1. Doctors use technology to better diagnose and treat illnesses in a less invasive manner. Prairie Business website. Available at: www.prairiebizmag.com. Accessed July 31, 2012.
2. Wachter RM. Bedside ultrasound for hospitalists: our time has come. Wachter’s World website. Available at: http://community.the-hospitalist.org/2012/05/16/bedside-ultrasound-for-hospitalists-our-time-has-come. Accessed July 31, 2012.
3. Mims C. Patent hints at iPad-powered portable ultrasound machine. Technology Review website. Available at: www.technologyreview.com/view/427600/patent-hints-at-ipad-powered-portable-ultrasound. Accessed July 29, 2012.

Prairie Business Magazine recently reported that hospitalist Neville Alberto, MD, FACP, of Sanford Health in Fargo, N.D., carries on his rounds not a stethoscope but “a portable ultrasound draped around his neck.”¹ The article illustrates ultrasound’s increased portability, wider application at the hospital bedside, and increased use by trained hospitalists. It’s a topic also discussed in a recent post by Robert Wachter, MD, MHM, author of the blog Wachter’s World, professor, and chief of the division of hospital medicine at the University of California at San Francisco (UCSF). Dr. Wachter says “the time has come to—carefully and thoughtfully—add hospitalists” to the growing list of medical specialties that have staked a claim to a procedure previously reserved for radiologists.²

“The one I carry on me is no larger than my smartphone,” Dr. Alberto explains. “It’s well-placed, so nobody notices.”

A hospitalist since 2001, Dr. Alberto is often on the move in his seven-story hospital building. He uses the device to assist in determining whether a patient needs more fluids, or to examine an elderly patient’s bladder for urinary retention when a urinary tract infection is suspected. Only a few colleagues in Dr. Alberto’s 22-member hospitalist group are as comfortable with ultrasound technology, he says, but he has helped develop a curriculum to teach ultrasound techniques to physicians, residents, and medical students.

Diane Sliwka, MD, a UCSF hospitalist and advocate for more widespread ultrasound use by hospitalists, says most physicians have yet to adopt the technology as fully as Dr. Alberto has. “But they’ve seen it and they want it,” she adds.

Hospitalists first utilized portable ultrasound to guide such procedures as thoracentesis or paracentesis. Increasingly, it is being used to assess, for example, cardiac function, fluid buildup around the heart, or the location of a blood clot—“when decisions are needed quickly about what’s going on and how to treat it,” she says. Other growing targets include lung pathologies (pneumothorax) and differentiating between COPD and pulmonary edema, or pneumonia and gallstones, she says.

The technology is advancing faster than the speed of light, with an iPad/tablet application in the works, according to a recent Technology Review blog post from the Massachusetts Institute of Technology.³

References

1. Doctors use technology to better diagnose and treat illnesses in a less invasive manner. Prairie Business website. Available at: www.prairiebizmag.com. Accessed July 31, 2012.
2. Wachter RM. Bedside ultrasound for hospitalists: our time has come. Wachter’s World website. Available at: http://community.the-hospitalist.org/2012/05/16/bedside-ultrasound-for-hospitalists-our-time-has-come. Accessed July 31, 2012.
3. Mims C. Patent hints at iPad-powered portable ultrasound machine. Technology Review website. Available at: www.technologyreview.com/view/427600/patent-hints-at-ipad-powered-portable-ultrasound. Accessed July 29, 2012.

Prairie Business Magazine recently reported that hospitalist Neville Alberto, MD, FACP, of Sanford Health in Fargo, N.D., carries on his rounds not a stethoscope but “a portable ultrasound draped around his neck.”¹ The article illustrates ultrasound’s increased portability, wider application at the hospital bedside, and increased use by trained hospitalists. It’s a topic also discussed in a recent post by Robert Wachter, MD, MHM, author of the blog Wachter’s World, professor, and chief of the division of hospital medicine at the University of California at San Francisco (UCSF). Dr. Wachter says “the time has come to—carefully and thoughtfully—add hospitalists” to the growing list of medical specialties that have staked a claim to a procedure previously reserved for radiologists.²

“The one I carry on me is no larger than my smartphone,” Dr. Alberto explains. “It’s well-placed, so nobody notices.”

A hospitalist since 2001, Dr. Alberto is often on the move in his seven-story hospital building. He uses the device to assist in determining whether a patient needs more fluids, or to examine an elderly patient’s bladder for urinary retention when a urinary tract infection is suspected. Only a few colleagues in Dr. Alberto’s 22-member hospitalist group are as comfortable with ultrasound technology, he says, but he has helped develop a curriculum to teach ultrasound techniques to physicians, residents, and medical students.

Diane Sliwka, MD, a UCSF hospitalist and advocate for more widespread ultrasound use by hospitalists, says most physicians have yet to adopt the technology as fully as Dr. Alberto has. “But they’ve seen it and they want it,” she adds.

Hospitalists first utilized portable ultrasound to guide such procedures as thoracentesis or paracentesis. Increasingly, it is being used to assess, for example, cardiac function, fluid buildup around the heart, or the location of a blood clot—“when decisions are needed quickly about what’s going on and how to treat it,” she says. Other growing targets include lung pathologies (pneumothorax) and differentiating between COPD and pulmonary edema, or pneumonia and gallstones, she says.

The technology is advancing faster than the speed of light, with an iPad/tablet application in the works, according to a recent Technology Review blog post from the Massachusetts Institute of Technology.³

References

1. Doctors use technology to better diagnose and treat illnesses in a less invasive manner. Prairie Business website. Available at: www.prairiebizmag.com. Accessed July 31, 2012.
2. Wachter RM. Bedside ultrasound for hospitalists: our time has come. Wachter’s World website. Available at: http://community.the-hospitalist.org/2012/05/16/bedside-ultrasound-for-hospitalists-our-time-has-come. Accessed July 31, 2012.
3. Mims C. Patent hints at iPad-powered portable ultrasound machine. Technology Review website. Available at: www.technologyreview.com/view/427600/patent-hints-at-ipad-powered-portable-ultrasound. Accessed July 29, 2012.

Share of physician job-search assignments conducted by Irving, Texas-based physician recruiting firm Merritt Hawkins from April 1, 2011, and March 31, 2012, that featured openings for independent, solo practitioners; the share was 17% in 2006.¹ Merritt Hawkins’ 2012 Review of Physician Recruiting Incentives report concludes “the recruitment of physicians into solo practice settings has almost abated.” Conversely, 63% of the firm’s job searches were with hospitals, up from 56% the year before.

Reference

1. Merritt Hawkins. 2012 Review of Physician Recruiting Incentives. Merritt Hawkins website. Available at: http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/mha2012survpreview.pdf. Accessed July 23, 2012.

Share of physician job-search assignments conducted by Irving, Texas-based physician recruiting firm Merritt Hawkins from April 1, 2011, and March 31, 2012, that featured openings for independent, solo practitioners; the share was 17% in 2006.¹ Merritt Hawkins’ 2012 Review of Physician Recruiting Incentives report concludes “the recruitment of physicians into solo practice settings has almost abated.” Conversely, 63% of the firm’s job searches were with hospitals, up from 56% the year before.

Reference

1. Merritt Hawkins. 2012 Review of Physician Recruiting Incentives. Merritt Hawkins website. Available at: http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/mha2012survpreview.pdf. Accessed July 23, 2012.

Share of physician job-search assignments conducted by Irving, Texas-based physician recruiting firm Merritt Hawkins from April 1, 2011, and March 31, 2012, that featured openings for independent, solo practitioners; the share was 17% in 2006.¹ Merritt Hawkins’ 2012 Review of Physician Recruiting Incentives report concludes “the recruitment of physicians into solo practice settings has almost abated.” Conversely, 63% of the firm’s job searches were with hospitals, up from 56% the year before.

Reference

1. Merritt Hawkins. 2012 Review of Physician Recruiting Incentives. Merritt Hawkins website. Available at: http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/mha2012survpreview.pdf. Accessed July 23, 2012.

An interactive program to teach quality and leadership skills to internal-medicine residents at Mount Sinai School of Medicine in New York City—described in an Research, Innovations and Clinical Vignettes (RIV) poster presented at HM12 in San Diego—found that medical trainees are eager and willing to learn the skills that will be required from hospitalists in a reformed healthcare system.¹ Lead author Brian Markoff, MD, SFHM, associate chief of hospital medicine at Mount Sinai, says the Healthcare Leadership Track’s elective, one-month block in quality improvement (QI) and patient safety was established with four second-year residents in 2011-2012.

Along with didactic presentations, participants were offered novel structured learning exercises that included:

• Teaching a care-transitions module to interns;
• Proposing a new clinical pathway;
• Leading a conference on QI;
• Examining a hospital readmission for what went wrong;
• Pairing with a ward medical director;
• Conducting a mentored QI research project; and
• Participating in a book club.

All four participants from the first year “strongly agree that the block was highly relevant to their current and future careers,” Dr. Markoff says.

In their third year, the residents will have the opportunity to participate in one-month electives for leadership, teaching, and the business of medicine.

Six new second-year residents are joining the program, and longitudinal components span the program’s two years. “Most institutions that train residents have a lot of this activity going on,” he says. “Why not get house staff involved in experiential learning in these areas?”

Reference

1. Markoff B, Dunn A. Healthcare leadership track: a novel track to train leaders in inpatient medicine. Paper presented at: HM12, Society of Hospital Medicine annual meeting; April 1-4, 2012; San Diego.

An interactive program to teach quality and leadership skills to internal-medicine residents at Mount Sinai School of Medicine in New York City—described in an Research, Innovations and Clinical Vignettes (RIV) poster presented at HM12 in San Diego—found that medical trainees are eager and willing to learn the skills that will be required from hospitalists in a reformed healthcare system.¹ Lead author Brian Markoff, MD, SFHM, associate chief of hospital medicine at Mount Sinai, says the Healthcare Leadership Track’s elective, one-month block in quality improvement (QI) and patient safety was established with four second-year residents in 2011-2012.

Along with didactic presentations, participants were offered novel structured learning exercises that included:

• Teaching a care-transitions module to interns;
• Proposing a new clinical pathway;
• Leading a conference on QI;
• Examining a hospital readmission for what went wrong;
• Pairing with a ward medical director;
• Conducting a mentored QI research project; and
• Participating in a book club.

All four participants from the first year “strongly agree that the block was highly relevant to their current and future careers,” Dr. Markoff says.

In their third year, the residents will have the opportunity to participate in one-month electives for leadership, teaching, and the business of medicine.

Six new second-year residents are joining the program, and longitudinal components span the program’s two years. “Most institutions that train residents have a lot of this activity going on,” he says. “Why not get house staff involved in experiential learning in these areas?”

Reference

1. Markoff B, Dunn A. Healthcare leadership track: a novel track to train leaders in inpatient medicine. Paper presented at: HM12, Society of Hospital Medicine annual meeting; April 1-4, 2012; San Diego.

An interactive program to teach quality and leadership skills to internal-medicine residents at Mount Sinai School of Medicine in New York City—described in an Research, Innovations and Clinical Vignettes (RIV) poster presented at HM12 in San Diego—found that medical trainees are eager and willing to learn the skills that will be required from hospitalists in a reformed healthcare system.¹ Lead author Brian Markoff, MD, SFHM, associate chief of hospital medicine at Mount Sinai, says the Healthcare Leadership Track’s elective, one-month block in quality improvement (QI) and patient safety was established with four second-year residents in 2011-2012.

Along with didactic presentations, participants were offered novel structured learning exercises that included:

• Teaching a care-transitions module to interns;
• Proposing a new clinical pathway;
• Leading a conference on QI;
• Examining a hospital readmission for what went wrong;
• Pairing with a ward medical director;
• Conducting a mentored QI research project; and
• Participating in a book club.

All four participants from the first year “strongly agree that the block was highly relevant to their current and future careers,” Dr. Markoff says.

In their third year, the residents will have the opportunity to participate in one-month electives for leadership, teaching, and the business of medicine.

Six new second-year residents are joining the program, and longitudinal components span the program’s two years. “Most institutions that train residents have a lot of this activity going on,” he says. “Why not get house staff involved in experiential learning in these areas?”

Reference

1. Markoff B, Dunn A. Healthcare leadership track: a novel track to train leaders in inpatient medicine. Paper presented at: HM12, Society of Hospital Medicine annual meeting; April 1-4, 2012; San Diego.

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

“Do you understand what I just told you?”

Hospitalists who are experts on communicating with patients say that this kind of simple, yes/no question can engender all sorts of confusion. This kind of query often results in unrealistic discharge plans, failed post-discharge treatments, and unnecessary rehospitalizations. And they happen all the time in hospitals across the country.

“Yes/no questions, unless they are very concrete—such as ‘Do you have a headache?’—have little relation to assessing a patient’s understanding of essential healthcare information,” says Jeffrey Greenwald, MD, SFHM, hospitalist and educator at Massachusetts General Hospital in Boston. Many times, he adds, patients say “yes” just to please the doctor or nurse, or to avoid looking ignorant.

A better approach to patient-provider communication, one that successfully addresses communication gaps, is teach-back, a strategy in which providers ask patients to repeat (or “teach back”), in their own words, what they have just learned about their medical condition, treatments, and self-care. For example, a physician using the teach-back method could ask, “Mr. Smith, can you tell me why you are in the hospital?”

The approach is an integral part of SHM’s Project BOOST (Better Outcomes for Older Adults through Safer Transitions) care-transitions quality initiative, says Dr. Greenwald, a BOOST coinvestigator. But too often, hospitalists fail to embrace the mandate of effective communication, he says, leaving responsibility to clarify the patient’s understanding to nurses and other members of the care team.

“Having taught this skill all over the country, I continue to find members of my own profession who feel that it is not their job to assess if patients understand self-care and medication instructions. To me, there’s no question that physicians have a role to play as teachers. We educate patients, whether we think we do or not,” Dr. Greenwald says, adding that some hospitalists do so with greater effectiveness than others.

In an era of accountable-care organizations, patient-centered care, and shared decision-making, hospitalists need to provide their patients the same core messages as the rest of the care team does. According to a recent report by the University of California San Francisco (UCSF) Center for Vulnerable Populations at San Francisco General Hospital, 77 million Americans have difficulty understanding even basic healthcare information.¹

In addition to widespread language barriers, the Institute of Medicine in a 2004 report concluded that 90 million U.S. adults have literacy skills that test below the high-school level.² As most hospitalists know, many inpatients go to great lengths to mask these limitations—appearing knowledgeable while failing to grasp essential health concepts. Medical jargon, acronyms, and instructions can be confusing, even for patients with a high level of education.

“First and foremost, we have to be able to communicate with our patients—to make sure that we understand their goals and that they understand our approach to treatment and the therapeutic goals we are proposing,” Dr. Greenwald says. “This process also helps to achieve true informed consent. We want to ensure that their questions are being answered, and that the options we are discussing are in line with their goals of care so that they are more likely to actually undertake them when they go home. And if they can’t, we need to know that in advance, so that we can intervene in other ways.”

Embracing the Method

One health system that has embraced teach-back as a patient-education strategy is the Lehigh Valley Health Network (LVHN), a 988-bed, three-hospital system based in Allentown, Pa. In an HM12 workshop, the Lehigh Valley team explained how its teach-back initiative grew out of quality initiatives to target patient flow and readmissions. Lehigh joined an Institute for Healthcare Improvement quality collaborative, implemented “Lean” quality-improvement (QI) methodologies, and adopted a patient-coaching program.³

“This process has shined a stark spotlight on how poorly we as physicians communicate with patients overall,” says Michael Pistoria, DO, SFHM, former hospitalist and president of medical staff at LVHN who was a member of the teach-back team.

“I’d like to think I’m a little above averagein this regard, but it has made me realize how much better I could be in checking in with patients, gauging their health literacy, and engaging them with the care plan. As hospitalists, we all have to rethink how we talk to patients and families.”

A multidisciplinary team, originally created to analyze care transitions, was divided into four work groups. One group, which focused on patient/family understanding of the disease process, quickly learned that care-team members often failed to identify the patient’s “key learner”—the patient, a family member, or someone else. If the information is given to the wrong person, breakdowns can result. Such breakdowns usually lead to readmissions. One instrumental change that came as a result of the QI team’s efforts is that LVHN care-team members now recognize it is their responsibility to ask who the key learner is and to put that person’s name on a whiteboard in the patient’s room.

In the workshop in at SHM’s annual meeting in San Diego, Kim Jordan, MHA, BSN, RN, NE-BC, LVHN’s administrator of patient-care services, described teach-back as an effective, easy-to-use communication strategy that improves patient learning outcomes. “We created a standard work process using teach-back strategies across the healthcare system,” with training offered to all professionals who provide education to patients and families, she said.

Starting with heart failure, prompts were written into the electronic health record (EHR) to provide four scripted teach-back questions, each focused on the patient’s knowledge, attitudes, and behavior, to be asked consecutively over three days. Information was “chunked” into manageable pieces, emphasizing what was most important for the patient to learn on that day.

Results from one of the pilot units showed 30-day readmission rates for heart failure patients were cut in half, from 28% to 14%.⁴ Teach-back scripts also are being developed for the anticoagulant clinic and for patients with stroke, myocardial infarction, chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, and diabetes.

“Continued analysis continues to show reduced rehospitalizations, and we even find that for those who are readmitted, their second admissions have been shorter,” Dr. Pistoria says, noting LVHN nurses have reported higher satisfaction. “They say, ‘This is wonderful. This is what I love about nursing—I get to teach the patients.’”

A Quality Mandate

The importance of effective communication with hospitalized patients is recognized in the federal Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)⁵ quality ratings and, more recently, by Consumers Union’s new hospital safety ratings,⁶ which include communication in its six categories of patient-safety measures. And a recent study from the University of Washington says patients place high value on verbal communication about their discharge care plans and how to improve their health, and personal communication between their inpatient and outpatient providers.⁷

Large volumes of important information often are “dumped” on hospitalized patients, and many times patients are provided insufficient time to assimilate the information or ask questions about it.⁸ Such situations are especially common at discharge. And although physicians and other care-team members might feel they can’t afford the time to assure themselves that the patient understands what they are saying, the alternative is a lot more time spent dealing with preventable crises, misunderstandings—and preventable readmissions.

“People say, ‘I don’t have time for this,’” says Laura Vento, MSN, RN, clinical nurse leader on an acute-care medical unit at the University of California at San Diego medical center, who spearheaded teach-back at her hospital. “I did some observations around discharge visits, and it took an average of six minutes. After we implemented teach-back, it took eight to nine minutes. Nurses and patients were both very satisfied with the results. I say to staff: ‘Give it a try, and see what a difference an extra two minutes can make.’”

Dr. Pistoria describes teach-back as “humble inquiry...the simple need and ability to ask patients, ‘I know I’ve been throwing a lot of information at you. Can you tell me what I just said?’ Then, shut up and listen.” The goal is to have patients confirm that they understand fully what the provider thinks they need to know. The technique is presented as a test not of the patient’s learning ability, but of the provider’s communication effectiveness and success in explaining the information (see Figure 1). If the message has not been transmitted successfully, the professional reteaches, corrects misconceptions, and again asks the patient to teach back.

The theory is that physicians will then avoid the closed-ended questions (“Do you understand what I just told you?”) that make patients uncomfortable or inhibit the communication that needs to happen between patient and provider.

“We didn’t invent teach-back, which long predated Project BOOST,” Dr. Greenwald says. “But we use it and endorse it strongly, and believe it is an important part of communication with patients, particularly around care transitions.”

Dr. Greenwald thinks teach-back “is not a big stretch for hospitalists.” But he says it requires meaningful training and practice, ideally in a multidisciplinary team context. Participating Project BOOST ([email protected]) and Electronic Quality Improvement Programs (eQUIPS) sites receive a two-year license to post the “train-the-trainer” curriculum on their intranet systems.⁸ An instructional webinar, and the trainer curriculum and video, are available in the SHM store (www.hospitalmedicine.org/store). SHM also provides on-site training sessions for health systems or learning collaboratives (contact [email protected]).

click for large version

‘Teach-Back on Steroids’

Teach-back, while a useful approach for improving patients’ understanding about hospital discharges, post-discharge care plans, and patient self-care, is just one of many teaching models that hospitalist groups can use to improve provider-to-patient communication. HM groups should assess health literacy in their regions and physician communication skills before deciding on one or more improvement tools.

LVHN, for example, has incorporated brief motivational interviewing techniques to its teach-back system, and the results are now being studied, says Paula Robinson, MSN, RN, BC, LVHN’s manager of patient, family, and consumer education.

“A lot of research out there emphasizes how patient education and knowledge alone don’t make a difference in adherence or compliance to treatment plans, even if they are getting the knowledge right 100% of the time,” Robinson says. “You also need to give patients permission to explore their feelings.”

One of Robinson’s colleagues, patient-care specialist Debra Peters, MSN, RN, BC, CMSRN, remembers using teach-back with a heart failure patient with recurrent rehospitalizations, exploring why it was important to control his salt intake. “The patient said, ‘Honey, I salt my ham, and I have no intention of changing that.’ This issue would not have come up if we had just addressed the knowledge component and told him: ‘You need to reduce your salt intake.’”

There might not be easy solutions to that kind of patient attitude, although in this case Peters made a referral to a dietitian who worked with the patient on food substitutions and other tools for managing his salt intake. “I don’t know if we made a big difference, but I haven’t seen him back in the hospital,” she says.

Motivational interviewing is a directive, client-centered counseling style for eliciting behavioral changes by helping clients to explore and resolve their ambivalence about making changes.⁹ Robinson calls it “the next step in our journey, with teach-back as a jumping-off place. We’ve worked on open-ended questions, getting patients to tell their stories, and our own reflective listening skills. I look at teach-back as a great communication tool and strategy—and motivational interviewing as ‘teach-back on steroids.’”

A number of similar, comparable, or complementary techniques and systems, with names like “Teach-to-Goal” and often paired with such resources as written materials, can help advance the same ends (visit the-hospitalist.org to learn about a technique for communicating bad news to patients).

The Flinders Program, developed at Flinders University in Adelaide, Australia, is a four-part structured motivational interview that asks patients to identify what they see as the biggest problem they face.¹⁰ LVHN medical educator Krista Hirschmann, MA, PhD, says this method was taught at LVHN by Australian experts and is now being used by its home-care department. “It is truly a patient-centered approach, and could be used by anybody in the health system,” she says.

Project RED (Re-Engineered Discharge), a care-transitions strategy developed by Brian Jack, MD, and colleagues at Boston University School of Medicine, was used to create a “virtual discharge advocate,” a computer avatar that simulates the face-to-face interaction between a patient and a nurse at the bedside.¹¹ Patients interact with the avatar, named Louise, through a touch-screen display to review their after-hospital care packet and to answer her questions, confirming their understanding without being rushed for time.

Ultimately, Dr. Greenwald says, it doesn’t matter if physicians use teach-back or some other system to improve health literacy. “What matters is whether your patients understand what they need to know in order to go home and take care of themselves,” he says.

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Brach C, Keller D, Hernandez LM, et al. Ten attributes of health literate health care organizations. Institute of Medicine of the National Academies website. Available at: http://iom.edu/Global/Perspectives/2012/HealthLitAttributes.aspx. Accessed Aug. 9, 2012.
2. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds., Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington: Institute of Medicine; 2004.
3. Care Transitions Program; University of Colorado School of Medicine, Division of Health Care Policy and Research. Available at: www.caretransitions.org. Accessed July 28, 2012.
4. Healthcare Benchmarks and Quality Improvement. Teach-back program reduces readmissions. HighBeam Research website. Available at: http://www.highbeam.com/doc/1G1-269890846.html. Accessed Aug. 9, 2012.
5. Hospital Consumer Assessment of Healthcare Providers and Systems. Centers for Medicare & Medicaid Services website. Available at: www.hcahpsonline.org. Accessed July 23, 2012.
6. Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed Aug. 1, 2012.
7. Shoeb M, Merel SE, Jackson MB, Anawalt BD. “Can’t we just stop and talk?” Patients value verbal communication about discharge care plans. J Hosp Med. 2012;7(6):504-7.
8. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.
9. Borrelli B, Riekert KA, Weinstein W, Rathier L. Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. J Allergy Clinical Immunol. 2007;120(5):1023-30.
10. eQUIPS (Electronic Quality Improvement Programs). Society of Hospital Medicine website. Available at: http:// www.hospitalmedicine.org/equips. Accessed Aug. 1, 2012.
11. Kelly J, Kubina N. Navigating self-management: a practical approach for Australian health agencies. Flinders University, Adelaide, Australia. Available at: www.flinders.edu.au/medicine/sites/fhbhru/self-management.cfm. Accessed Aug. 1, 2012.
12. Project RED (Re-Engineered Discharge). Boston University Medical Center website. Available at: http:// www.bu.edu/fammed/projectred/publications.html. Accessed Aug. 1, 2012.

“Do you understand what I just told you?”

Hospitalists who are experts on communicating with patients say that this kind of simple, yes/no question can engender all sorts of confusion. This kind of query often results in unrealistic discharge plans, failed post-discharge treatments, and unnecessary rehospitalizations. And they happen all the time in hospitals across the country.

“Yes/no questions, unless they are very concrete—such as ‘Do you have a headache?’—have little relation to assessing a patient’s understanding of essential healthcare information,” says Jeffrey Greenwald, MD, SFHM, hospitalist and educator at Massachusetts General Hospital in Boston. Many times, he adds, patients say “yes” just to please the doctor or nurse, or to avoid looking ignorant.

A better approach to patient-provider communication, one that successfully addresses communication gaps, is teach-back, a strategy in which providers ask patients to repeat (or “teach back”), in their own words, what they have just learned about their medical condition, treatments, and self-care. For example, a physician using the teach-back method could ask, “Mr. Smith, can you tell me why you are in the hospital?”

The approach is an integral part of SHM’s Project BOOST (Better Outcomes for Older Adults through Safer Transitions) care-transitions quality initiative, says Dr. Greenwald, a BOOST coinvestigator. But too often, hospitalists fail to embrace the mandate of effective communication, he says, leaving responsibility to clarify the patient’s understanding to nurses and other members of the care team.

“Having taught this skill all over the country, I continue to find members of my own profession who feel that it is not their job to assess if patients understand self-care and medication instructions. To me, there’s no question that physicians have a role to play as teachers. We educate patients, whether we think we do or not,” Dr. Greenwald says, adding that some hospitalists do so with greater effectiveness than others.

In an era of accountable-care organizations, patient-centered care, and shared decision-making, hospitalists need to provide their patients the same core messages as the rest of the care team does. According to a recent report by the University of California San Francisco (UCSF) Center for Vulnerable Populations at San Francisco General Hospital, 77 million Americans have difficulty understanding even basic healthcare information.¹

In addition to widespread language barriers, the Institute of Medicine in a 2004 report concluded that 90 million U.S. adults have literacy skills that test below the high-school level.² As most hospitalists know, many inpatients go to great lengths to mask these limitations—appearing knowledgeable while failing to grasp essential health concepts. Medical jargon, acronyms, and instructions can be confusing, even for patients with a high level of education.

“First and foremost, we have to be able to communicate with our patients—to make sure that we understand their goals and that they understand our approach to treatment and the therapeutic goals we are proposing,” Dr. Greenwald says. “This process also helps to achieve true informed consent. We want to ensure that their questions are being answered, and that the options we are discussing are in line with their goals of care so that they are more likely to actually undertake them when they go home. And if they can’t, we need to know that in advance, so that we can intervene in other ways.”

Embracing the Method

One health system that has embraced teach-back as a patient-education strategy is the Lehigh Valley Health Network (LVHN), a 988-bed, three-hospital system based in Allentown, Pa. In an HM12 workshop, the Lehigh Valley team explained how its teach-back initiative grew out of quality initiatives to target patient flow and readmissions. Lehigh joined an Institute for Healthcare Improvement quality collaborative, implemented “Lean” quality-improvement (QI) methodologies, and adopted a patient-coaching program.³

“This process has shined a stark spotlight on how poorly we as physicians communicate with patients overall,” says Michael Pistoria, DO, SFHM, former hospitalist and president of medical staff at LVHN who was a member of the teach-back team.

“I’d like to think I’m a little above averagein this regard, but it has made me realize how much better I could be in checking in with patients, gauging their health literacy, and engaging them with the care plan. As hospitalists, we all have to rethink how we talk to patients and families.”

A multidisciplinary team, originally created to analyze care transitions, was divided into four work groups. One group, which focused on patient/family understanding of the disease process, quickly learned that care-team members often failed to identify the patient’s “key learner”—the patient, a family member, or someone else. If the information is given to the wrong person, breakdowns can result. Such breakdowns usually lead to readmissions. One instrumental change that came as a result of the QI team’s efforts is that LVHN care-team members now recognize it is their responsibility to ask who the key learner is and to put that person’s name on a whiteboard in the patient’s room.

In the workshop in at SHM’s annual meeting in San Diego, Kim Jordan, MHA, BSN, RN, NE-BC, LVHN’s administrator of patient-care services, described teach-back as an effective, easy-to-use communication strategy that improves patient learning outcomes. “We created a standard work process using teach-back strategies across the healthcare system,” with training offered to all professionals who provide education to patients and families, she said.

Starting with heart failure, prompts were written into the electronic health record (EHR) to provide four scripted teach-back questions, each focused on the patient’s knowledge, attitudes, and behavior, to be asked consecutively over three days. Information was “chunked” into manageable pieces, emphasizing what was most important for the patient to learn on that day.

Results from one of the pilot units showed 30-day readmission rates for heart failure patients were cut in half, from 28% to 14%.⁴ Teach-back scripts also are being developed for the anticoagulant clinic and for patients with stroke, myocardial infarction, chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, and diabetes.

“Continued analysis continues to show reduced rehospitalizations, and we even find that for those who are readmitted, their second admissions have been shorter,” Dr. Pistoria says, noting LVHN nurses have reported higher satisfaction. “They say, ‘This is wonderful. This is what I love about nursing—I get to teach the patients.’”

A Quality Mandate

The importance of effective communication with hospitalized patients is recognized in the federal Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)⁵ quality ratings and, more recently, by Consumers Union’s new hospital safety ratings,⁶ which include communication in its six categories of patient-safety measures. And a recent study from the University of Washington says patients place high value on verbal communication about their discharge care plans and how to improve their health, and personal communication between their inpatient and outpatient providers.⁷

Large volumes of important information often are “dumped” on hospitalized patients, and many times patients are provided insufficient time to assimilate the information or ask questions about it.⁸ Such situations are especially common at discharge. And although physicians and other care-team members might feel they can’t afford the time to assure themselves that the patient understands what they are saying, the alternative is a lot more time spent dealing with preventable crises, misunderstandings—and preventable readmissions.

“People say, ‘I don’t have time for this,’” says Laura Vento, MSN, RN, clinical nurse leader on an acute-care medical unit at the University of California at San Diego medical center, who spearheaded teach-back at her hospital. “I did some observations around discharge visits, and it took an average of six minutes. After we implemented teach-back, it took eight to nine minutes. Nurses and patients were both very satisfied with the results. I say to staff: ‘Give it a try, and see what a difference an extra two minutes can make.’”

Dr. Pistoria describes teach-back as “humble inquiry...the simple need and ability to ask patients, ‘I know I’ve been throwing a lot of information at you. Can you tell me what I just said?’ Then, shut up and listen.” The goal is to have patients confirm that they understand fully what the provider thinks they need to know. The technique is presented as a test not of the patient’s learning ability, but of the provider’s communication effectiveness and success in explaining the information (see Figure 1). If the message has not been transmitted successfully, the professional reteaches, corrects misconceptions, and again asks the patient to teach back.

The theory is that physicians will then avoid the closed-ended questions (“Do you understand what I just told you?”) that make patients uncomfortable or inhibit the communication that needs to happen between patient and provider.

“We didn’t invent teach-back, which long predated Project BOOST,” Dr. Greenwald says. “But we use it and endorse it strongly, and believe it is an important part of communication with patients, particularly around care transitions.”

Dr. Greenwald thinks teach-back “is not a big stretch for hospitalists.” But he says it requires meaningful training and practice, ideally in a multidisciplinary team context. Participating Project BOOST ([email protected]) and Electronic Quality Improvement Programs (eQUIPS) sites receive a two-year license to post the “train-the-trainer” curriculum on their intranet systems.⁸ An instructional webinar, and the trainer curriculum and video, are available in the SHM store (www.hospitalmedicine.org/store). SHM also provides on-site training sessions for health systems or learning collaboratives (contact [email protected]).

click for large version

‘Teach-Back on Steroids’

Teach-back, while a useful approach for improving patients’ understanding about hospital discharges, post-discharge care plans, and patient self-care, is just one of many teaching models that hospitalist groups can use to improve provider-to-patient communication. HM groups should assess health literacy in their regions and physician communication skills before deciding on one or more improvement tools.

LVHN, for example, has incorporated brief motivational interviewing techniques to its teach-back system, and the results are now being studied, says Paula Robinson, MSN, RN, BC, LVHN’s manager of patient, family, and consumer education.

“A lot of research out there emphasizes how patient education and knowledge alone don’t make a difference in adherence or compliance to treatment plans, even if they are getting the knowledge right 100% of the time,” Robinson says. “You also need to give patients permission to explore their feelings.”

One of Robinson’s colleagues, patient-care specialist Debra Peters, MSN, RN, BC, CMSRN, remembers using teach-back with a heart failure patient with recurrent rehospitalizations, exploring why it was important to control his salt intake. “The patient said, ‘Honey, I salt my ham, and I have no intention of changing that.’ This issue would not have come up if we had just addressed the knowledge component and told him: ‘You need to reduce your salt intake.’”

There might not be easy solutions to that kind of patient attitude, although in this case Peters made a referral to a dietitian who worked with the patient on food substitutions and other tools for managing his salt intake. “I don’t know if we made a big difference, but I haven’t seen him back in the hospital,” she says.

Motivational interviewing is a directive, client-centered counseling style for eliciting behavioral changes by helping clients to explore and resolve their ambivalence about making changes.⁹ Robinson calls it “the next step in our journey, with teach-back as a jumping-off place. We’ve worked on open-ended questions, getting patients to tell their stories, and our own reflective listening skills. I look at teach-back as a great communication tool and strategy—and motivational interviewing as ‘teach-back on steroids.’”

A number of similar, comparable, or complementary techniques and systems, with names like “Teach-to-Goal” and often paired with such resources as written materials, can help advance the same ends (visit the-hospitalist.org to learn about a technique for communicating bad news to patients).

The Flinders Program, developed at Flinders University in Adelaide, Australia, is a four-part structured motivational interview that asks patients to identify what they see as the biggest problem they face.¹⁰ LVHN medical educator Krista Hirschmann, MA, PhD, says this method was taught at LVHN by Australian experts and is now being used by its home-care department. “It is truly a patient-centered approach, and could be used by anybody in the health system,” she says.

Project RED (Re-Engineered Discharge), a care-transitions strategy developed by Brian Jack, MD, and colleagues at Boston University School of Medicine, was used to create a “virtual discharge advocate,” a computer avatar that simulates the face-to-face interaction between a patient and a nurse at the bedside.¹¹ Patients interact with the avatar, named Louise, through a touch-screen display to review their after-hospital care packet and to answer her questions, confirming their understanding without being rushed for time.

Ultimately, Dr. Greenwald says, it doesn’t matter if physicians use teach-back or some other system to improve health literacy. “What matters is whether your patients understand what they need to know in order to go home and take care of themselves,” he says.

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Brach C, Keller D, Hernandez LM, et al. Ten attributes of health literate health care organizations. Institute of Medicine of the National Academies website. Available at: http://iom.edu/Global/Perspectives/2012/HealthLitAttributes.aspx. Accessed Aug. 9, 2012.
2. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds., Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington: Institute of Medicine; 2004.
3. Care Transitions Program; University of Colorado School of Medicine, Division of Health Care Policy and Research. Available at: www.caretransitions.org. Accessed July 28, 2012.
4. Healthcare Benchmarks and Quality Improvement. Teach-back program reduces readmissions. HighBeam Research website. Available at: http://www.highbeam.com/doc/1G1-269890846.html. Accessed Aug. 9, 2012.
5. Hospital Consumer Assessment of Healthcare Providers and Systems. Centers for Medicare & Medicaid Services website. Available at: www.hcahpsonline.org. Accessed July 23, 2012.
6. Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed Aug. 1, 2012.
7. Shoeb M, Merel SE, Jackson MB, Anawalt BD. “Can’t we just stop and talk?” Patients value verbal communication about discharge care plans. J Hosp Med. 2012;7(6):504-7.
8. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.
9. Borrelli B, Riekert KA, Weinstein W, Rathier L. Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. J Allergy Clinical Immunol. 2007;120(5):1023-30.
10. eQUIPS (Electronic Quality Improvement Programs). Society of Hospital Medicine website. Available at: http:// www.hospitalmedicine.org/equips. Accessed Aug. 1, 2012.
11. Kelly J, Kubina N. Navigating self-management: a practical approach for Australian health agencies. Flinders University, Adelaide, Australia. Available at: www.flinders.edu.au/medicine/sites/fhbhru/self-management.cfm. Accessed Aug. 1, 2012.
12. Project RED (Re-Engineered Discharge). Boston University Medical Center website. Available at: http:// www.bu.edu/fammed/projectred/publications.html. Accessed Aug. 1, 2012.

“Do you understand what I just told you?”

Hospitalists who are experts on communicating with patients say that this kind of simple, yes/no question can engender all sorts of confusion. This kind of query often results in unrealistic discharge plans, failed post-discharge treatments, and unnecessary rehospitalizations. And they happen all the time in hospitals across the country.

“Yes/no questions, unless they are very concrete—such as ‘Do you have a headache?’—have little relation to assessing a patient’s understanding of essential healthcare information,” says Jeffrey Greenwald, MD, SFHM, hospitalist and educator at Massachusetts General Hospital in Boston. Many times, he adds, patients say “yes” just to please the doctor or nurse, or to avoid looking ignorant.

A better approach to patient-provider communication, one that successfully addresses communication gaps, is teach-back, a strategy in which providers ask patients to repeat (or “teach back”), in their own words, what they have just learned about their medical condition, treatments, and self-care. For example, a physician using the teach-back method could ask, “Mr. Smith, can you tell me why you are in the hospital?”

The approach is an integral part of SHM’s Project BOOST (Better Outcomes for Older Adults through Safer Transitions) care-transitions quality initiative, says Dr. Greenwald, a BOOST coinvestigator. But too often, hospitalists fail to embrace the mandate of effective communication, he says, leaving responsibility to clarify the patient’s understanding to nurses and other members of the care team.

“Having taught this skill all over the country, I continue to find members of my own profession who feel that it is not their job to assess if patients understand self-care and medication instructions. To me, there’s no question that physicians have a role to play as teachers. We educate patients, whether we think we do or not,” Dr. Greenwald says, adding that some hospitalists do so with greater effectiveness than others.

In an era of accountable-care organizations, patient-centered care, and shared decision-making, hospitalists need to provide their patients the same core messages as the rest of the care team does. According to a recent report by the University of California San Francisco (UCSF) Center for Vulnerable Populations at San Francisco General Hospital, 77 million Americans have difficulty understanding even basic healthcare information.¹

In addition to widespread language barriers, the Institute of Medicine in a 2004 report concluded that 90 million U.S. adults have literacy skills that test below the high-school level.² As most hospitalists know, many inpatients go to great lengths to mask these limitations—appearing knowledgeable while failing to grasp essential health concepts. Medical jargon, acronyms, and instructions can be confusing, even for patients with a high level of education.

“First and foremost, we have to be able to communicate with our patients—to make sure that we understand their goals and that they understand our approach to treatment and the therapeutic goals we are proposing,” Dr. Greenwald says. “This process also helps to achieve true informed consent. We want to ensure that their questions are being answered, and that the options we are discussing are in line with their goals of care so that they are more likely to actually undertake them when they go home. And if they can’t, we need to know that in advance, so that we can intervene in other ways.”

Embracing the Method

One health system that has embraced teach-back as a patient-education strategy is the Lehigh Valley Health Network (LVHN), a 988-bed, three-hospital system based in Allentown, Pa. In an HM12 workshop, the Lehigh Valley team explained how its teach-back initiative grew out of quality initiatives to target patient flow and readmissions. Lehigh joined an Institute for Healthcare Improvement quality collaborative, implemented “Lean” quality-improvement (QI) methodologies, and adopted a patient-coaching program.³

“This process has shined a stark spotlight on how poorly we as physicians communicate with patients overall,” says Michael Pistoria, DO, SFHM, former hospitalist and president of medical staff at LVHN who was a member of the teach-back team.

“I’d like to think I’m a little above averagein this regard, but it has made me realize how much better I could be in checking in with patients, gauging their health literacy, and engaging them with the care plan. As hospitalists, we all have to rethink how we talk to patients and families.”

A multidisciplinary team, originally created to analyze care transitions, was divided into four work groups. One group, which focused on patient/family understanding of the disease process, quickly learned that care-team members often failed to identify the patient’s “key learner”—the patient, a family member, or someone else. If the information is given to the wrong person, breakdowns can result. Such breakdowns usually lead to readmissions. One instrumental change that came as a result of the QI team’s efforts is that LVHN care-team members now recognize it is their responsibility to ask who the key learner is and to put that person’s name on a whiteboard in the patient’s room.

In the workshop in at SHM’s annual meeting in San Diego, Kim Jordan, MHA, BSN, RN, NE-BC, LVHN’s administrator of patient-care services, described teach-back as an effective, easy-to-use communication strategy that improves patient learning outcomes. “We created a standard work process using teach-back strategies across the healthcare system,” with training offered to all professionals who provide education to patients and families, she said.

Starting with heart failure, prompts were written into the electronic health record (EHR) to provide four scripted teach-back questions, each focused on the patient’s knowledge, attitudes, and behavior, to be asked consecutively over three days. Information was “chunked” into manageable pieces, emphasizing what was most important for the patient to learn on that day.

Results from one of the pilot units showed 30-day readmission rates for heart failure patients were cut in half, from 28% to 14%.⁴ Teach-back scripts also are being developed for the anticoagulant clinic and for patients with stroke, myocardial infarction, chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, and diabetes.

“Continued analysis continues to show reduced rehospitalizations, and we even find that for those who are readmitted, their second admissions have been shorter,” Dr. Pistoria says, noting LVHN nurses have reported higher satisfaction. “They say, ‘This is wonderful. This is what I love about nursing—I get to teach the patients.’”

A Quality Mandate

The importance of effective communication with hospitalized patients is recognized in the federal Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)⁵ quality ratings and, more recently, by Consumers Union’s new hospital safety ratings,⁶ which include communication in its six categories of patient-safety measures. And a recent study from the University of Washington says patients place high value on verbal communication about their discharge care plans and how to improve their health, and personal communication between their inpatient and outpatient providers.⁷

Large volumes of important information often are “dumped” on hospitalized patients, and many times patients are provided insufficient time to assimilate the information or ask questions about it.⁸ Such situations are especially common at discharge. And although physicians and other care-team members might feel they can’t afford the time to assure themselves that the patient understands what they are saying, the alternative is a lot more time spent dealing with preventable crises, misunderstandings—and preventable readmissions.

“People say, ‘I don’t have time for this,’” says Laura Vento, MSN, RN, clinical nurse leader on an acute-care medical unit at the University of California at San Diego medical center, who spearheaded teach-back at her hospital. “I did some observations around discharge visits, and it took an average of six minutes. After we implemented teach-back, it took eight to nine minutes. Nurses and patients were both very satisfied with the results. I say to staff: ‘Give it a try, and see what a difference an extra two minutes can make.’”

Dr. Pistoria describes teach-back as “humble inquiry...the simple need and ability to ask patients, ‘I know I’ve been throwing a lot of information at you. Can you tell me what I just said?’ Then, shut up and listen.” The goal is to have patients confirm that they understand fully what the provider thinks they need to know. The technique is presented as a test not of the patient’s learning ability, but of the provider’s communication effectiveness and success in explaining the information (see Figure 1). If the message has not been transmitted successfully, the professional reteaches, corrects misconceptions, and again asks the patient to teach back.

The theory is that physicians will then avoid the closed-ended questions (“Do you understand what I just told you?”) that make patients uncomfortable or inhibit the communication that needs to happen between patient and provider.

“We didn’t invent teach-back, which long predated Project BOOST,” Dr. Greenwald says. “But we use it and endorse it strongly, and believe it is an important part of communication with patients, particularly around care transitions.”

Dr. Greenwald thinks teach-back “is not a big stretch for hospitalists.” But he says it requires meaningful training and practice, ideally in a multidisciplinary team context. Participating Project BOOST ([email protected]) and Electronic Quality Improvement Programs (eQUIPS) sites receive a two-year license to post the “train-the-trainer” curriculum on their intranet systems.⁸ An instructional webinar, and the trainer curriculum and video, are available in the SHM store (www.hospitalmedicine.org/store). SHM also provides on-site training sessions for health systems or learning collaboratives (contact [email protected]).

click for large version

‘Teach-Back on Steroids’

Teach-back, while a useful approach for improving patients’ understanding about hospital discharges, post-discharge care plans, and patient self-care, is just one of many teaching models that hospitalist groups can use to improve provider-to-patient communication. HM groups should assess health literacy in their regions and physician communication skills before deciding on one or more improvement tools.

LVHN, for example, has incorporated brief motivational interviewing techniques to its teach-back system, and the results are now being studied, says Paula Robinson, MSN, RN, BC, LVHN’s manager of patient, family, and consumer education.

“A lot of research out there emphasizes how patient education and knowledge alone don’t make a difference in adherence or compliance to treatment plans, even if they are getting the knowledge right 100% of the time,” Robinson says. “You also need to give patients permission to explore their feelings.”

One of Robinson’s colleagues, patient-care specialist Debra Peters, MSN, RN, BC, CMSRN, remembers using teach-back with a heart failure patient with recurrent rehospitalizations, exploring why it was important to control his salt intake. “The patient said, ‘Honey, I salt my ham, and I have no intention of changing that.’ This issue would not have come up if we had just addressed the knowledge component and told him: ‘You need to reduce your salt intake.’”

There might not be easy solutions to that kind of patient attitude, although in this case Peters made a referral to a dietitian who worked with the patient on food substitutions and other tools for managing his salt intake. “I don’t know if we made a big difference, but I haven’t seen him back in the hospital,” she says.

Motivational interviewing is a directive, client-centered counseling style for eliciting behavioral changes by helping clients to explore and resolve their ambivalence about making changes.⁹ Robinson calls it “the next step in our journey, with teach-back as a jumping-off place. We’ve worked on open-ended questions, getting patients to tell their stories, and our own reflective listening skills. I look at teach-back as a great communication tool and strategy—and motivational interviewing as ‘teach-back on steroids.’”

A number of similar, comparable, or complementary techniques and systems, with names like “Teach-to-Goal” and often paired with such resources as written materials, can help advance the same ends (visit the-hospitalist.org to learn about a technique for communicating bad news to patients).

The Flinders Program, developed at Flinders University in Adelaide, Australia, is a four-part structured motivational interview that asks patients to identify what they see as the biggest problem they face.¹⁰ LVHN medical educator Krista Hirschmann, MA, PhD, says this method was taught at LVHN by Australian experts and is now being used by its home-care department. “It is truly a patient-centered approach, and could be used by anybody in the health system,” she says.

Project RED (Re-Engineered Discharge), a care-transitions strategy developed by Brian Jack, MD, and colleagues at Boston University School of Medicine, was used to create a “virtual discharge advocate,” a computer avatar that simulates the face-to-face interaction between a patient and a nurse at the bedside.¹¹ Patients interact with the avatar, named Louise, through a touch-screen display to review their after-hospital care packet and to answer her questions, confirming their understanding without being rushed for time.

Ultimately, Dr. Greenwald says, it doesn’t matter if physicians use teach-back or some other system to improve health literacy. “What matters is whether your patients understand what they need to know in order to go home and take care of themselves,” he says.

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Brach C, Keller D, Hernandez LM, et al. Ten attributes of health literate health care organizations. Institute of Medicine of the National Academies website. Available at: http://iom.edu/Global/Perspectives/2012/HealthLitAttributes.aspx. Accessed Aug. 9, 2012.
2. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds., Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington: Institute of Medicine; 2004.
3. Care Transitions Program; University of Colorado School of Medicine, Division of Health Care Policy and Research. Available at: www.caretransitions.org. Accessed July 28, 2012.
4. Healthcare Benchmarks and Quality Improvement. Teach-back program reduces readmissions. HighBeam Research website. Available at: http://www.highbeam.com/doc/1G1-269890846.html. Accessed Aug. 9, 2012.
5. Hospital Consumer Assessment of Healthcare Providers and Systems. Centers for Medicare & Medicaid Services website. Available at: www.hcahpsonline.org. Accessed July 23, 2012.
6. Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed Aug. 1, 2012.
7. Shoeb M, Merel SE, Jackson MB, Anawalt BD. “Can’t we just stop and talk?” Patients value verbal communication about discharge care plans. J Hosp Med. 2012;7(6):504-7.
8. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.
9. Borrelli B, Riekert KA, Weinstein W, Rathier L. Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. J Allergy Clinical Immunol. 2007;120(5):1023-30.
10. eQUIPS (Electronic Quality Improvement Programs). Society of Hospital Medicine website. Available at: http:// www.hospitalmedicine.org/equips. Accessed Aug. 1, 2012.
11. Kelly J, Kubina N. Navigating self-management: a practical approach for Australian health agencies. Flinders University, Adelaide, Australia. Available at: www.flinders.edu.au/medicine/sites/fhbhru/self-management.cfm. Accessed Aug. 1, 2012.
12. Project RED (Re-Engineered Discharge). Boston University Medical Center website. Available at: http:// www.bu.edu/fammed/projectred/publications.html. Accessed Aug. 1, 2012.